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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.
Because it’s a procedure needed by so many, a lot of people ask, “does Medicare cover 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 if you do not have insurance coverage.
Does Medicare Cover Knee Replacement Surgery?
The short answer is yes; Medicare will cover the cost of knee replacement surgery. Though it won’t cover it 100% of the time. As is usually the case with Medicare coverage, there are certain conditions you’ll have to meet 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.
Part A Coverage
Coverage for total knee replacement surgery is provided by Medicare Part A if you end up getting admitted to the hospital for your procedure. If that happens, then 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 have to pay a copay $371 for each day you are in the hospital. 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 a sizeable copayment each day.
Part B Coverage
For the most part, however, a lot of the parts of a knee replacement falls under Part B coverage. For example, before getting approved for knee surgery you’ll have to get some screenings and, possibly, try some non-surgical treatments. This will likely be done through your primary care physician.
Your primary care physician may end up referring you to an orthopedic physician. This is the type of doctor that specializes in knee pain. Since these doctor’s services are done on an outpatient basis, Medicare Part B will cover your visits.
Quite often orthopedic surgeons will perform knee surgeries at an outpatient surgical center. In this case, Part B will provide the coverage.
Medicare Part B covers 80 percent of the costs of total knee replacement surgery. You will pay for the remaining 20 percent.
Post Knee Surgery Coverage From Medicare
Again, if you need to stay in the hospital (or a skilled nursing facility) following your surgery, that will fall under Medicare Part A.
Once you go home, it’s pretty much certain you’ll need some follow up care. This can include post-surgery office visits to your physician, physical therapy and other follow up care. These treatments and services will fall under Part B.
Part C and Part D Coverage for Knee Replacement Surgery
Medicare Advantage plans (Medicare Part C) also provide coverage for total knee replacement surgery. These plans have to cover all the same treatments and services as Original Medicare. But they’ll also offer coverage for things that Original Medicare does not.
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 Knee Replacement Surgery Cost?
Knee replacement surgery costs around $37,000 if you have to pay for it out-of-pocket. This will vary depending on the type of knee replacement surgery you get (ie. total vs partial), the type of facility you go to (ie. hospital vs outpatient surgery center) and some other factors.
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?