2.The Long-term care Insurance System

(1) Aims for introducing the system

• To facilitate a system in which the society as a whole support those who are facing the need of long-term care, society's major cause of concern in terms of becoming old.
• To establish a system in which the relationship between benefits and burdens are made clear, by way of introducing a social insurance approach, which can easily gain public understanding.
• To reconstruct the present vertically-divided system between health, medical and welfare services, and to establish a system by which service users can receive comprehensive services from a variety of institutions of their choice.
• To separate long-term care from coverage of health care insurance, and to establish a system which aims to decrease cases of "social hospitalization" as the first step toward restructuring the social security system as a whole.

(2) Outline of the System

1) Insurers

• Insurers shall be municipalities and special wards in the metropolitan area. The central government, prefectures, health care insurers and pension insurers shall provide continuous 　support and assistance to them.

2) The insured, beneficiaries and premiums

	Category 1 insured persons	Category 2 insured persons
Eligible persons	Persons aged 65 or over	Persons aged 40 to 64 who are insured by health care insurance
Beneficiaries	・ Persons requiring long-term care (bedridden, dementia) ・ Persons requiring support (frail)	Those who have become bed-ridden, dementia, and/or frail be- cause of specific age-related diseases such as early-stage dementia, cerebro-vascular disorder, etc. (*)
Premiums	Collected by municipalities	Collected with premiums for health care insurance by health care insurers and paid in lump sums
Method　of levying　and　collection	・ Fixed premiums per income bracket (premiums for persons with low incomes shall be reduced) ・ Premiums shall be deducted from pension benefits above a given amount (180 thousand yen per year),otherwise they shall be collected directly by municipalities	・ Employees' Health Insurance → The amount of premiums is decided based on standardized amount of salary multiplied by long-term care premium rate (Employers bear part of the cost) ・ National Health Insurance: → The amount of premiums is decided based on the amount of income as well as fixed per-capita amount. (The government bears part of the cost)

(*)	For the time being, public funds will be used to provide young disabled persons with comprehensively programmed long-term care services, etc. in accordance with the Government Action Plan for Persons with Disabilities.

(3) Procedures for use

1)

Municipalities shall provide long-term care requirement certification and support requirement certification based on the screening judgement results of the long-term care approval board. The long-term care approval board will investigate the mental and physical condition of the insured person and make a screening judgement based on the opinions of a regular doctor. (The screening judgement can be entrusted to prefectures.) * Standards for long-term care requirement certification shall be uniformly and objectively determined nationwide. 　 Benefits which correspond to the level of long-term care required (a limit for benefits to be paid for home long-term care) will be determined. ○ In-home benefits will be determined depending on the level of long-term care required (6 levels including Support-required). ・ For home-visit outpatient services: 62,000 to 358,000 yen per month. (Amount differs with regions.) ・ For short-stay service: 7 to 42 days every 6 months. From January 2002, the limit for both services will be unified. ○ Facility benefits will also be determined in accordance to facility types, depending on the level of long-term care required. Limit for benefits paid for home long-term care services (To be unified in January 2002) 　 Home-visit commuting service Short-stay service (Not replacable) (Replacable) Support required 6,150 unit/month 1 week / half year 6 days / 1 month Care level 1 16,580 unit/month 2 week / half year 16 days / 1 month Care level 2 19,480 unit/month 2 week / half year 18 days / 1 month Care level 3 26,750 unit/month 3 week / half year 24 days / 1 month Care level 4 30,600 unit/month 3 week / half year 27 days / 1 month Care level 5 35,830 unit/month 6 week / half year 30 days / 1 month * 1 unit = 10 - 10.72 yen (Differs with regions and services) * 'Replacement' of 'Short stay service' is a measure for people who are having difficulty in in-home care due to advanced age, etc. and who live in municipalities which have, to some extent, room for bed usage. They can replace the remainder of each month's home-visit and outpatient service benefits with the limit of days for short-stay. (The limit for consecutive usage is 30 days. Except in cases when replacement of service is particularly required due to mental and physical conditions, approximately one half of the certified period can be replaced.)

2)

From the standpoint of providing comprehensive and planned service to accommodate the policyholder's demands, it is fundamental that a long-term care service plan (care plan) is decided.

(4) Insurance benefits

	In-home service	Services at facilities
Persons requiring long-term care	・ Home-visit/Day Services home-visit long-term care, home-visit bathing, home-visit rehabilitation, day rehabilitation (day care), home-visit nursing care, day service, welfare devices leasing ・ Short-stay service, short-stay care ・ In-home medical care management counseling ・ Care service with mutual support for the elderly with dementia ・ Care service provided in for-profit private homes for the elderly, etc. ・ Allowance for purchase of welfare devices ・ Allowance for home renovation (handrails, removal of level differences, etc.)	・ Long-term care welfare facilities for the elderly (Special nursing homes for the elderly) ・ Long-term care health facilities for the elderly ・ Long-term care medical facilities for the elderly - Sanatorium-type wards - Sanatorium-type wards for elderly patients with dementia - Hospitals with enhanced long-term care service provision (for three years after implementation)
Persons requiring support	Same as above (excluding care service with mutual support for the elderly with dementia)	N/A

(5) Costs

1)	Out-of-pocket payment at a fixed rate (10% of the cost of the insured services) and a standard charge for meals imposed on users of facility services (such as special nursing homes for the elderly).
2)	There is an upper limit of the above out-of-pocket payment.
3)	The upper limit of the out-of-pocket payment and standard charge for meals is set lower for people with low income.

(6) Expenses

*1

Percentage based on the population ratio of category 1 and category 2 insured persons.

*2

The government will be provided 5% to make adjustments for differences in municipalities' financial capabilities. (Percentage of subsidies are differ from each municipalities) (Reason for adjustments) (1) Differences in membership percentages of latter stage elderly persons. (2) Differences in elderly persons abilities to bear costs (income standards) (3) Special cases such as reduced and exempted premiums at times of emergencies

☆	Intermittent financial management shall be introduced, and premiums for category 1 insured persons will be revised once every 3 years.

(7) Insurance Premiums

• For the standpoint of having people bear the cost according to their ability to pay, the insurance premium of Category 1 insured people, in principle, shall be a fixed amount set by each municipality according to their income level. This reduces the burden on people with low income, meanwhile people with high income is bearing more expenses.

  Level	Eligible Persons	Premium	(Ref.) Estimated percentage of eligible persons
  1	・ Public assistance recipients ・ Municipal tax-exempted households and Old-Age Welfare Pension recipients	Basic amount x 0.5	Approx. 2%
  2	Municipal tax-exempted households	Basic amount x 0.75	Approx. 29%
  3	Municipal tax-exempted persons	Basic amount x 1	Approx. 43%
  4	Municipal tax payer (The insured person's total amount of income is less than 2,500,000 yen.)	Basic amount x 1.25	Approx. 16%
  5	Municipal tax payer (The insured person's total amount of income is 2,500,000 yen or more.)	Basic amount x 1.5	Approx. 10%

  
  

• The insurance premium of category 2 insured people shall be calculated by the method decided by their health care insurer. (The average cost per category 2 insured person is the same.)

(8) Preparation of the basis for provision of long-term care services

1)	In order to promote infrastructure of a long-term care service to progress in a systematic manner, municipalities must determine their plans for long-term care insurance services and prefectures must decide on their long-term care services and benefits respectively, based on fundamental policies decided by the government.
2)	When municipalities are to plan or to change the municipal long-term care insurance service plan, measures to reflect insured persons' opinions shall be taken.
3)	Municipalities that have difficulty securing the standard levels of benefits for home services determined by the government, can fix a standard level that is lower than the appropriate level, and raise this gradually to the level determined by regulations 5 years after implementation.

(9) Considerations for stabilizing system operations

＜Considerations of financial aspects＞

1)	The government will provide subsidies equivalent to 50% of the administrative expenses incurred for the newly added matters of long-term care requirement certification etc.
2)	Finance stabilizing funds shall be granted or loaned to prefectures, (the government, prefectures and Category 1 premiums shall each provide one third of the revenues), to make good financial deficits caused by increased payments resulting from benefits surpassing estimates, and declined rates of premium payments.

＜Considerations of business implementation aspects＞

• Prefectures may be entrusted with the screening judgement matters of long-term care requirement certification.
  Prefectures shall support the joint establishment of screening meetings for a number of municipalities.

(10) Implementation

April 1, 2000

(11) Considerations

• Necessary reconsideration and additional examination of the range of insured persons, levels and contents of benefits, ideal cost sharing of premiums and the long-term care insurance system in general, shall be carried out based on situational changes and social economic conditions.
• The opinions of local community groups, etc. shall be given full consideration when investigating system reforms.

Over 50% of care takers are over 60 years old.

85% of care takers are women

Previous system		Long-term care insurance system
(1) Apply at the administrative office window, and municipalities determine the service.	→	Users can choose the type of service and facilities they want to use.
(2) Apply separately for medical care and welfare.	→	Users will make a long-term care service usage plan (care plan) and use medical care and welfare services comprehensively.
(3) Service provided mainly by municipalities and public organizations (Council of Social Welfare, etc.).	→	Services provided by various organizations such as private companies, agricultural cooperatives, livelihood cooperatives, and volunteer organizations, etc.
(4) For middle and high income persons, services are hard to use due to expensive cost to bear. e.g. In the case of the householder's annual income is 8 million yen, and his or her elderly parent receives a pension of 200,000 yen per month: 　・ Special nursing home for the elderly will cost 190,000 per month 　・ Home helper service will cost 950 yen per hour.	→	Users will pay 10% charge for the service regardless of their income. e.g. In case of the householder's annual income is 8 million yen, and his or her elderly parent receives a pension of 200,000 yen per month: 　・ Special nursing home for the elderly will cost 50,000 per month 　・ Home helper service will cost 400 yen every 30 to 60 minutes.

Notes: 1.	The ratio of category 1 insured persons: Category 2 insured persons was assumed for FY 2000.
2.	Adjusted subsidies will be provided in relation to the percentage of latter stage elderly persons in each municipality, and their incomes, etc. Nationwide, this will amount to approx. 5% of the overall subsidy. However, subsidy adjustment rates are examples.