Source: http://aids-chushi.or.jp/English/social/05/1.html
Timestamp: 2017-09-20 09:25:27
Document Index: 343550947

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Day-to-day Life Services, Including Long-term Care- Social welfare system - Chugoku-Shikoku Regional AIDS Center
What kind of long-term care insurance system exists?
It is a system where elderly persons who require nursing care can use required health care services and welfare services comprehensively to live independent daily lives. The system is operated by municipalities. All persons aged 40 or over are eligible for long-term care insurance. People with insurance are divided into two categories: Category 1 insured persons (aged 65 or over), and Category 2 insured persons (aged 40 to 64).
How is the amount of premiums for long-term care insurance decided?
How and to whom premiums are paid varies for Category 1 insured persons and Category 2 insured persons. (Chart 1)
[Chart1]Eligibility and premiums for long-term care insurance
Eligible persons All persons aged 65 or over
of the premium Municipalities where residence registries are located
premium Each municipality decides the basic amount of the premium. The amount of premium varies in a phased manner according to individual income.
Two methods of payment exist: Ordinary collections and special collections
Ordinary collections: Persons whose annual pension benefits are less than 180,000 yen, and persons who receive no pension benefits, pay individually to municipalities.
Special collections: Pension recipients whose annual pension benefits are 180,000 yen or more (15,000 yen or more per month) have payments automatically deducted from their pension benefits.
Eligible persons Persons aged 40 to 64 who have health care insurance
of the premium Health insurance organization that is insuring a person (Written at the bottom of the health insurance card)
premium Calculation methods and amounts of premiums vary depending on the health insurance organization (*1) insuring the individual.
payment Long-term care insurance premiums are added to health care insurance premiums. They are collected as medical care insurance premiums.
(*1) About the long-term care insurance premium for Category 2 insured persons
If insured under the National Health Insurance: Premium amounts vary depending on family income and properties. Premium payments are made by each household, and heads of households pay premiums for all family members.
If insured by the government health insurance and the mutual aid association: Premium amounts vary depending on salary (monthly standardized rewards). Employers bear half of the premium.
What kind of persons can use the services under long-term care insurance?
Municipalities where eligible persons reside conduct nursing care screening. Among the persons insured by long-term care insurance, persons certified as "needing support" under the screening are entitled to the services. Conditions for using nursing care services vary for Category 1 insured persons and Category 2 insured persons.
[Chart2]Beneficiaries of services by category
Insured persons'
Category 1 insured
Municipalities where eligible persons reside conduct nursing care screening. Persons certified as "needing long-term care (1-5)" can use "nursing care services."
Persons certified as "needing support (1-2)" can use "preventive care services."
If persons are recognized as "not falling within the certification" (ie, are self-reliant), they cannot use the services under long-term care insurance.
Category 2 insured
(aged 40 o 64)
In cases where persons suffer conditions requiring nursing care attributed to (specified) diseases caused by the mental and physical changes that accompany aging, and are certified as "needing long-term care (1-5)," they can use "long-term care services."
In cases where persons are recognized as "not falling within the certification" (ie, are self-reliant), they cannot use the services under long-term care insurance.
What constitutes a condition requiring long-term care?
Eligible persons are defined as follows: "Due to physical or mental disorders, persons require nursing care on a continuing and steady basis for some or all basic functions of daily living, including bathing, urination, defecation and meals. And persons falling into one of several categories (needing long-term care 1-5) designated by the Ministry of Health, Labour, Welfare, depending on the individual level of care."
What constitutes a condition requiring support?
Eligible persons are defined as follows: "Due to physical or mental disorders, persons needing support to lessen a condition, or prevent the worsening of a condition, that requires nursing care on a continuing and steady basis for some or all basic functions of daily living, including bathing, urination, defecation and meals." Or, due to physical or mental disorders, persons expected to have a disadvantage in daily living on a continuing basis, and fall in categories designated (needing support) by the Ministry of Health, Labour and Welfare, depending on the level of support."
What diseases are included as the specified diseases?
The following list of 16 diseases, caused by the physical and mental changes that accompany aging, indicates the specified diseases. In cases where Category 2 insured persons (aged 40 to 64) suffer from following specified diseases and are certified as needing long-term care (or needing support), they can use long-term care services (or preventive care services).
List of specified diseases (16 diseases)
Cancer at terminal stage (Based on generally accepted medical knowledge, when doctors judge that someone has no chance of recovery.)
Osteoporosis following a bone fracture
Dementia in middle age (including Alzheimer's disease and cerebral vascular dementia)
Progressive supranuclear palsy, corticobasal degeneration and Parkinson's disease
Spinal carnal stenosis
Diabetic neuropathy, diabetic nephropathy and diabetic retinopathy
Osteoarthritis following significant deformity of both knee joints, or the hip joint.
What kinds of application procedures are necessary to use the services?
First, it is necessary to apply for certification of needing long-term care at your local municipality. Then, if you are certified as needing long-term care or needing support, you can use the services. Procedures No.1-No.5 (written immediately below) are required.
No.1 Application for the certification of needing long-term care
Persons apply for the certification of needing long-term care at the long-term care insurance counter of the municipality where they reside. As persons aged 65 or over are provided with long-term care insurance cards, they are asked to bring the cards to the counter. The application can be handled by the person himself, a family member, or an entity such as a designated in-home care support business, a long-term care facility or a community comprehensive support center.
No.2 At-home screening and submission of attending doctor's opinion
After the application, investigators visit the applicant's home, etc. and conduct an interview to assess the applicant's mental and physical condition and the level of care necessary. Submission of the attending doctor's opinion is also required. Based on the home screening and the attending doctor's opinion, the long-term care approval board receives and judges the applicant's condition, whether he or she is in need of long-term care or support, and if so what level of care is required.
No.3 Notification of certification results
Within 30 days after the application, a notice of results will be delivered from the municipality. The notice informs the applicant of the level of care certification, effective duration of certification, and the limits of the care service amount per month according to the level. Three levels exist in long-term care certification. (Chart 3) The certification becomes valid retroactively to the date of application. If the applicant is dissatisfied with the results, he or she can appeal to the "long-term care insurance board of review" for re-consideration.
[Chart3]Level of certification and available services
Persons can use long-term care services (care benefits)
Persons can use preventive care services (prevention benefits)
Persons cannot use long-term care services
However, elderly persons who are judged as "highly likely to need long-term care" at basic health checkups and other occasions can use programs designed to forestall needing care (community support programs).
No.4 Creation of long-term care service plans (care plans)
Before the start of services, long-term care service plans (care plans) and preventive care plans are created suited for each individual's life-style, based on the information received. (Chart 4)
[Chart4]Plan creation according to level of certification
Patients create long-term care service plans (care plans) with such persons as in-house care support professionals (care managers). Drawing up a care plan is free of charge. Patients and their family members can create their own care plans.
Preventive care service programs are created at community comprehensive support centers. Drawing up a service program is free of charge.
No.5 Use of services
Based on the created care plans, patients sign contracts with long-term care service businesses designated by prefectural governors, and start using the services.
What kinds of services are available under long-term care insurance?
Services under long-term care insurance vary for persons certified with a need for care (1-5) and persons certified as needing support (1-2). Chart 5 (below) is a simple depiction of the services available for persons certified with a need for care (1-5).
As for persons certified as needing support (1-2), please refer to the question "What kinds of preventive care are available?"
[Chart5]Care benefit services for persons certified with need for care (1-5)
Home care (home help)
Rehabilitation (day care)
Other in-home
In-home medical treatment management guidance
Provision of home renovation costs (application should be submitted before commencement of work)
Welfare equipment rental (*See Notes)
Sales of designated welfare equipment (only by designated businesses)
Nighttime home visit long-term care
Day service for persons with dementia
Small-scale, multifunctional, in-home long-term care
Daily-life group care for persons with dementia (group homes)
Daily-life care for persons at community-based special nursing homes for the aged
Short-stay daily-life services
Short-stay medical services
Welfare facilities for elderly persons requiring long-term care (special nursing homes for the elderly)
Health care facilities for elderly persons requiring long-term care (health care facilities for the elderly)
Sanatorium-type medical care facilities for elderly persons requiring long-term care (long-term beds and others)
(*Notes) There is a basic rule that persons certified with a need for care level 1 cannot use such items as wheelchairs, wheelchair accessories, special beds, special bed accessories, equipment for preventing bedsores, devices to change position, detectors for wandering aged persons with dementia, or lifts for mobility among rental welfare equipment items.
However, persons are allowed to use such items if their condition necessitates it. Please refer to in-house care support professionals (care managers) for details.
What kinds of services are available under preventive care services?
Persons certified as needing support (1-2) can use the preventive care services that are listed in Chart 6. Persons certified as needing support (1-2) cannot use in-facility services (such as special nursing homes for the elderly or health care facilities for the elderly) under the long-term care insurance.
[Chart 6]Preventive care services that persons needing support (1-2) can use.
Home-visit care for preventive care (home help)
Home-visit nursing for preventive care
Home-visit bathing care for preventive care
Home-visit rehabilitation for preventive care
Day care for preventive care
Day rehabilitation services for preventive care
In-home medical care management guidance for preventive care
Rental of welfare equipment for preventive care (*See notes)
Provision for home renovation costs (application should be submitted before commencement of work)
Sales of designated welfare equipment for preventive care (only by designated businesses)
Day services for persons with dementia for preventive care
Small-scale, multifunctional, in-home care for preventive care
Daily-life group care for the elderly with dementia for preventive care (available only for persons certified as needing support level 2)
Short-stay daily-life services for preventive care
Short-stay medical services for preventive care
(*Notes) There is a basic rule that persons certified as needing support level (1-2), they cannot use such items as wheelchairs, wheelchair accessories, special beds, special bed accessories, equipment for preventing bedsores, devices to change positions, detectors for wandering aged persons with dementia, or lifts for mobility among rental welfare equipment items. However, persons are allowed to use such items if their condition necessitates it. Please refer to in-house care support professionals (care managers) for details.
How much is the copayment for the services?
When people use the services under long-term care insurance, they pay in principle 10% for the service expenses. Limits to the services per month under long-term care insurance are decided according to the kinds of services that patients use and the level of need for care. When use of the services under long-term care insurance exceeds the limit, patients are asked to pay 100% of the amount over the limit.
In cases where a patient uses the services without having a care service usage plan (care plan).
The user is asked to pay all the expenses up front. They can later be remunerated with an amount equivalent to 90% of the expenses, after applying to their municipality.
In cases where the 10% copayment of the service exceeds the specified amount per month for a patient
Limits for copayment per month for patients are decided according to household income. In cases where a patient's payment exceeds the limit, the overage amount can be refunded as "high long-term care service expenses," after applying at the long-term care insurance counter. However, in a case where they paid to purchase welfare equipment and/or home renovation costs, paid as housing and food expenses for in-facility service patients, and made copayments exceeding the service benefit limit, the payment will not be covered under the high long-term care service expenses refund.
In cases where patients use in-facility services
Food and housing expenses are required in addition to the 10% copayment for services.
In cases where patients purchase welfare equipment
Patients are asked to apply at the long-term care insurance counter at their local municipality before making the purchase. The maximum amount that patients can be provided from long-term care insurance per year is set at 100,000 yen, and they are required to pay 10% of this payment. Patients are asked to pay the entire amount to the business. Afterwards, 90% of the expense will be remunerated to the patients. Please consult with care support professionals (care managers) or personnel at long-term care insurance counters.
In cases where patients renovate their homes
Before starting construction, patients are required to submit an application at the long-term care insurance counter of municipalities. The maximum amount that patients can be provided from the long-term care insurance per year is set at 200,000 yen, and they are required to pay 10% of the payment. Patients are asked to pay the entire amount to the business. Afterwards, 90% of the expense will be remunerated to the patients. Please consult with care support professionals (care managers) or personnel at long-term care insurance counters.
Can patients alleviate service expenses?
Depending on the circumstances, in some cases patients can utilize a system where they can alleviate service expenses. (Chart 7) To utilize the system, some procedures are required at such places as the long-term care insurance counter.Please consult with care support professionals (care managers) or personnel at long-term care insurance counters.
[Chart 7]Examples where patients might utilize the system to alleviate their service expenses:
Patients are extremely impoverished as the income of their primary wage-earner(s) dropped sharply due to reasons such as unemployment or hospitalization.
Members of low-income households need long-term care services exceeding the limits due to severely intractable diseases and/or dementia.
Among the long-term care services provided by social welfare corporations, patients use care services that are covered by alleviation rules.
Medical expense assistance certificate holders for the severely disabled use services that are covered by alleviation rules.
Atomic bomb survivor's certificate holders use the services that are covered by reduction and exemption rules.
What kinds of roles do care support professionals (care managers) play?
"Care manager" is a qualification given by prefectural governors. Persons with the qualification consult with patients and their family members regarding long-term care and engage in support and other activities for long-term care service usage. To utilize long-term care services, a long-term care service usage plan (care plan) is required. To create a plan, comprehensive and detailed information, as well as expertise regarding long-term care services, is required. Care managers work at such facilities as in-home care support offices, long-term care insurance facilities and community-based comprehensive support centers.
What does the community-based comprehensive support center do?
The center is the local consultation bureau that provides comprehensive support to the elderly so they can continue to live independently in the communities where they have long resided. Municipalities are responsible for the centers, and either they or corporations commissioned by the municipalities operate them. The centers are obliged to maintain a professional staff consisting of chief care managers, public health nurses, caseworkers and so on. Staff members are engaged in cooperative consultations and support.
The centers also serve as consultation bureaus for such services as preventive care service usage, human rights advocacy for the elderly, and long-term care and money management.
HIV and Social Welfare INDEX >> 5.Day-to-day Life Services, Including Long-term Care