Treatment Costs and the High-Cost Medical Expense Benefit

1. The Big Picture and the Monthly Cap

The Big Picture

Every treatment for lumbar spinal stenosis and chronic low back pain is covered by national health insurance: conservative care, decompression and fusion surgery, and SCS alike. At the counter you pay 10 to 30 percent of the bill, depending on your age and income, never the full amount.

Conservative care adds up to a few tens of thousands of yen a year. Surgery and SCS have a much larger total bill, but your payment has a ceiling, set by the High-Cost Medical Expense Benefit. Ask the hospital's patient support office for an estimate based on your own income category.

The High-Cost Medical Expense Benefit — a Monthly Cap

Public insurance sets an upper limit on what you pay at the counter in one calendar month. Anything above the limit is refunded when you apply. The limit depends on your age and income.

Caps from August 2026 (through July 2027)

The scheme was revised from August 2026 (stage 1). In August 2027 the income categories will be subdivided further (stage 2, below).

Under 70 (monthly)

Aged 70 and over (monthly)

Worked example: someone under 70 earning ¥3.7–7.7M who has a ¥3,000,000 operation in one month pays ¥85,800 + (3,000,000 − 286,000) × 1% = about ¥113,000 for that month. Even for a very large bill, only 1% is added on top of the base cap.

If your annual income is under about ¥2M, the annual cap is ¥410,000 (refunded from August 2027). The "frequent-user cap" applies from the fourth month in any twelve in which you reach the cap.

Stage 2 from August 2027

• The five income categories become thirteen, with higher caps for middle and upper incomes (for example ¥98,100 + 1% for ¥5.1–6.5M, ¥110,400 + 1% for ¥6.5–7.7M). The ¥3.7–5.1M band stays at ¥85,800 + 1%.
• For people 70 and over in the general category, the outpatient cap stays at ¥22,000 up to about ¥2M of income and becomes ¥28,000 for ¥2–3.7M. The household cap becomes three steps: ¥61,500, ¥65,400, ¥69,600.
• The frequent-user cap for incomes under about ¥2M falls from ¥44,400 to ¥34,500.
• The way you use the scheme (certificate, My Number card) does not change.

What Changed in August 2026

1. Monthly caps rose in every income category (for example, under 70 at ¥3.7–7.7M: ¥80,100 → ¥85,800 + 1%; 70 and over, general, outpatient: ¥18,000 → ¥22,000).
2. The frequent-user cap is frozen, so people in long-term treatment do not pay more.
3. A new annual cap was introduced. Once your out-of-pocket total from August to the following July reaches the annual cap, the rest is refunded by your insurer. This also covers people whose monthly bills never reach the monthly cap. A refund under the annual cap may require an application, so read the notices from your insurer.

2. Surgery, SCS, and Paying at the Counter

Four Points Specific to Surgery and SCS

1. The cap is counted per calendar month

The benefit is calculated per calendar month (1st to last day). In SCS, if a trial is done, it and the permanent implant are separate hospital stays. If they fall in different months, you may pay up to the cap in each month; if both fall in the same month, you pay once. The same applies to a stay that starts at the end of one month and ends at the start of the next. Keep this in mind when dates are being set.

2. The frequent-user cap kicks in across months

If you reach the cap in three or more months within the last twelve, the cap drops from the fourth month. A trial, an implant, and follow-up visits within a few months can bring you into this reduction.

3. Meals and private-room charges are not covered

Hospital meal charges and private-room fees (差額ベッド代) are outside the High-Cost Medical Expense Benefit and are paid in addition to the cap. You can discuss a shared room versus a private room with the hospital before admission.

4. Future admissions use the same scheme

An SCS pulse generator will eventually need a battery replacement. That admission, like any re-operation after decompression or fusion, counts as that month's medical bill under the same scheme. The benefit is not a one-time allowance.

Avoiding Overpayment at the Counter

The eligibility certificate (限度額適用認定証) — before admission

Get a limit-application eligibility certificate from your insurer in advance and show it at the hospital counter; your payment is then capped from the start.

The My Number health insurance card

Using your My Number card as your insurance card gives the same treatment at most hospitals without a paper certificate. A few facilities do not support it, so check once your admission date is set.

Applying afterwards

You can also pay in full and apply to your insurer for a refund. The refund typically takes two to three months.

3. Other Schemes and Where to Ask

Other Schemes Worth Knowing

Where to Ask, and How to Ask Your Doctor

• The hospital's patient support office or medical social worker: an estimate based on your income category
• Your insurer's counter: the certificate and the annual-cap procedure
• Your doctor: "How much will this cost, and does the High-Cost Medical Expense Benefit apply?" This is not a rude question.

Three things to do today

1. Check your co-payment rate on your insurance card
2. Once admission is set, apply for the eligibility certificate (or prepare your My Number card)
3. Keep a year's receipts together

4. Common Questions and Sources

Frequently Asked Questions

Q. I've heard SCS is expensive. What will I actually pay?

The total bill is large, but what you pay is capped at your income category's monthly limit. Two things to know in advance: if a trial is done and falls in a different month from the implant, that can mean two months at the cap, and meals and private-room charges are extra. The hospital's patient support office can give you a figure for your own category.

Q. I was admitted without the certificate.

You can still apply afterwards and be refunded for anything above the cap (allow two to three months). The certificate can also be applied for during your stay; a family member can visit the counter for you.

Q. Do I have to apply every month?

Most insurers pay automatically in later months once you have applied (some National Health Insurance municipalities require a new application each time). With the certificate or My Number card, the counter payment itself is capped, so there is nothing to claim back.

Read next

→ Comparing Treatment Options: benefits, costs, risks, and long-term outlook by treatment

→ Spinal Cord Stimulation (SCS): how it works and what implantation involves

→ Questions to Ask Your Doctor: checklists by situation, including cost questions

→ Supporting a Family Member: how to apply for long-term care insurance

Sources

• Ministry of Health, Labour and Welfare, Revision of the High-Cost Medical Expense Benefit (from August 2026 treatment), updated July 2026
• Ministry of Health, Labour and Welfare, For Those Using the High-Cost Medical Expense Benefit
• Japan Health Insurance Association (協会けんぽ), When medical costs are high — meal charges, differential bed charges, and the non-covered portion of mixed care are outside the benefit

This information is general guidance. Amounts depend on your income category, the facility, and the date of treatment. Confirm your own category and procedures with your insurer, the hospital counter, and your doctor.