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Does Medicare Cover Shoulder Replacement Surgery?

Does Medicare Cover Shoulder Replacement Surgery?

Many people have shoulder pain and discomfort at some point in their lives. The risk of shoulder pain increases as we age, especially for those who have put a lot of stress on their shoulder joint.

Severe and recurrent shoulder pain may need medical attention. And in the worst cases, if the pain is unbearable, replacement surgery may be the only way to relieve the pain. 

If you or a loved one is thinking about shoulder replacement surgery, a common question you may have is, “Does Medicare cover shoulder replacement surgery?”

In this article, we answer the question in clear, plain English. You will also find the average cost of shoulder replacement surgery and additional helpful info.

Does Medicare Cover Shoulder Replacement Surgery?

The short answer is yes; Medicare will cover the cost of shoulder replacement surgery. But it may not cover it 100% of the time. As is often the case with Medicare, you must meet certain conditions for Medicare to pay. Below we look at what these are so you know what to expect.

Original Medicare Coverage of Shoulder Replacement Surgery

Original Medicare (Medicare Part A and Part B) provides coverage for shoulder replacement surgery. But, a doctor must say that it is a medically necessary procedure to get coverage. If that’s the case and your healthcare provider orders the operation, then Medicare can cover it.

Is Coverage Provided by Part A or Part B?

The answer is both! It depends on the setting. Medicare Part A covers your surgery if it takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days. 

Starting from the 61st day up to 90 days, Medicare Part A will still provide coverage. However, you will be responsible for paying a daily copayment. After 90 days, Medicare Part A will no longer provide coverage. 

But Medicare Part A does provide 60 lifetime reserve days. So, if you have these, you will be covered after 90 days. But, again, you will have a copayment you will be responsible for.

Part B Coverage of Shoulder Replacement Surgery

Shoulder replacement surgery often occurs in an outpatient setting, meaning coverage usually falls under Medicare Part B.

Once approved, Medicare Part B covers 80 percent of the costs of shoulder replacement surgery. You will pay for the remaining 20 percent. 

Medicare Advantage Coverage of Shoulder Replacement Surgery

Medicare Advantage plans (Medicare Part C) also provide coverage for shoulder replacement surgery. This is because these plans must cover the same treatments and procedures that Original Medicare covers.

While these plans, at a minimum, have to cover the same things as Parts A and B, they offer additional benefits Original Medicare does not offer. Exactly what these extra benefits are and how much the out-of-pocket costs are will vary from plan to plan.

Part D Coverage

Medicare Part D plans cover medications that you need after shoulder replacement surgery. Medicare Part D is a prescription drug plan. Like Medicare Part C, Medicare Part D plans are provided by private insurance companies.

How Much Does Shoulder Replacement Surgery Cost?

Without health insurance coverage, a shoulder replacement surgery may cost anywhere from $7,000 to $21,000. 

What Are The Types Of Shoulder Replacement Surgeries?

  • Rotator cuff tear surgery
  • Repeated shoulder dislocation surgery
  • Surgery for a fractured shoulder
  • A surgery caused by severe arthritis

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

Additional Info on Medicare Coverage

This article is part of our series on “What does Medicare cover?”

Also, you can check out other articles in this series, including: Does Medicare Cover Cosentyx?

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