Treatment Costs and the High-Cost Medical Expense Benefit

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, the trial and the permanent implant are separate procedures. 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. Knowing this in advance helps 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.