Osteoarthritis is one of the leading causes for people to undergo knee replacement surgery. In fact, nearly 800,000 people undergo knee replacement surgery every year in the U.S.
So a common question many people have is, “does Medicare cover total knee replacement surgery?” In this article, we answer that question in clear, plain English. You will also find the average costs of total knee replacement surgery and other helpful info.
Does Medicare Cover Total Knee Replacement Surgery?
The short answer is yes; Medicare will cover the cost of total knee replacement surgery. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your total knee replacement surgery. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for total knee replacement surgery. Parts A and B provide coverage for total knee replacement surgery if it is considered medically necessary by your healthcare provider.
Coverage for total knee replacement surgery is provided by Medicare Part A if it takes place in an inpatient setting such as a hospital. Medicare Part A covers the following for total knee replacement surgery:
- General nursing
- Semi-private room
- Medications that are given while the patient is inpatient
- Inpatient hospital services
Medicare Part A will provide full coverage for up to 60 days in an inpatient setting. From days 61 to 90, Medicare Part A will still provide coverage, but you will pay a copay $371 per day in 2021. After 90 days, Medicare Part A will no longer provide coverage.
However, Medicare Part A provides 60 lifetime reserve days. Using those, Medicare will still provide coverage for your hospital stay after 90 days but you will pay for a copayment of $742 per day.
Coverage for total knee replacement surgery is provided by Medicare Part B if it takes place in an outpatient setting. Medicare Part B also provides coverage for doctor’s visits before and after the surgery, as well as the Durable Medical Equipment, or DME, that you need after the surgery.
Medicare Part B covers 80 percent of the costs of total knee replacement surgery. You will pay for the remaining 20 percent.
Part C and Part D Coverage for Total Knee Replacement Surgery
Medicare Advantage plans (Medicare Part C) also provide coverage for total knee replacement surgery. They cover everything Original Medicare covers, as well as some additional benefits. However, exactly what it covers and your out-of-pocket costs will vary depending on the specifics of your plan.
Medicare Part D plans provide coverage for medications that you need after the total knee replacement surgery. Medicare Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.
How Much Does Total Knee Replacement Surgery Cost?
Total knee replacement surgery costs around $35,000 or higher. This will vary depending on the provider.
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 handicap showers?