Medicare covers most healthcare services when ordered by a licensed provider.
If you’re in need of knee replacement surgery, Original Medicare Part A (hospital insurance) and Part B (medical insurance) will cover various aspects of the costs, including recovery, as long as your doctor indicates the surgery is medically necessary.
Knee replacement surgery is relatively common (more than 750,000 per year), but is still a major procedure that includes weeks or months of preparation before and recovery after. Understanding how Medicare will cover your surgery and recovery is an important step in preparing.
Does Medicare Pay for Knee Replacements?
Medicare covers surgical procedures that are deemed medically necessary by your doctor, so in order for your knee replacement surgery to be covered, your doctor must deem it medically necessary. There is no Medicare knee replacement age limit, though you must be enrolled in Medicare.
Depending on which kind of knee surgery you get, it may be covered by either Part A or Part B. Medications you may have to take after the surgery for reducing pain and risk of infection will be covered by Part D.
Part A Coverage
If the surgery is an inpatient procedure, it will be covered by Part A. Most people have surgery as an inpatient and only have to stay at the hospital for a few days post-surgery. Additionally, Part A may cover:
An eligible stay in a skilled nursing facility (if you have a qualifying hospital stay of at least three days prior to your admission)
Hospital services such as
- General nursing
- Medication while in the hospital
- Inpatient services, such as imaging and labs
Part B Coverage
If the surgery is an outpatient procedure, it will be covered by Part B. Additionally, Part B will cover up to 80% of:
- Doctor visits, both before and after the surgery
- Medically necessary physical or occupational therapy services
- Durable medical equipment (DME) such as a cane or walker
Does a Medicare Advantage Plan Cover Knee Replacement?
Part C plans (Medicare Advantage) are required to cover everything Original Medicare does. If you have an MA plan, your surgery would be covered under either Part A or Part B as listed above. The primary difference may be the cost - your MA plan may have a lower deductible or out-of-pocket costs for the procedure or prescriptions.
Additionally, your plan may cover more durable medical equipment than Original Medicare does.
Does a Medicare Supplement Plan Cover Knee Replacement Surgery?
If you have a Medicare Supplement plan, it may cover some or even all of your out-of-pocket costs associated with knee replacement surgery under Part A and Part B. However, you will still have to pay your monthly premiums.
Some Medicare Supplement plans may also cover your Part A and Part B deductibles and coinsurance amounts, but likely will not cover Part D prescription drug costs.
What Is the Cost of a Total Knee Replacement If You Are on Medicare?
The cost of a knee replacement can range from $20,000 - $40,000 or more. However, your costs for a total knee replacement vary based on a number of factors, including (but not limited to):
- Your Medicare coverage
- The type of procedure you need
- How long the operation takes
- Where you live
- Where you have surgery
- Whether you have complications or not
- The type of care you’ll need after surgery
- Medications you’re prescribed after surgery
- Number of inpatient hospital days after the surgery
- Physical therapy necessary
Before your surgery, asking your doctor if the surgery is medically necessary, whether you’ll be having inpatient or outpatient surgery, and estimated out-of-pocket costs will help you understand what you may have to pay, and what may be covered by Medicare.
Here is a breakdown of estimated out-of-pocket costs for a total knee replacement. To avoid unexpected costs, talk with your doctor and the hospital you are receiving the surgery at to understand how much the procedure and aftercare will cost, including medication and physical therapy.
You must meet your Part A deductible (if an inpatient) before Medicare starts paying, which is $1,600 (in 2023). You will also have to meet your Part B deductible before Medicare begins to pay. In 2023, this amount is $226.
For prescription drugs, you must meet the Part D deductible of $505 (in 2023).
If your surgery is covered by Part A, you will have no coinsurance as long as you stay in the hospital for less than 60 days.
After you meet your Part B deductible, you will be responsible for 20% coinsurance of the remaining cost. Medicare will cover the remaining 80%.
Part D prescription drug coverage should cover necessary medications for pain and therapy after your procedure, but you may have to pay a copay for these drugs.
Costs with a Medicare Advantage Plan
If you have a Medicare Advantage plan, your out-of-pocket costs may be different, even lower, than those on Original Medicare. Additionally, many MA plans include Part D coverage, so you could avoid incurring additional prescription costs. Call your plan prior to the surgery to ask about coverage and costs.
Alternatives to Knee Surgery
Depending on your circumstances, Medicare may cover alternatives to knee surgery, including:
- Viscosupplementation. This procedure injects hyaluronic acid into the knee joint to help lubricate the damaged joint, reduce pain, improve movement and slow down osteoarthritis progression.
- Nerve therapy. This involves shifting of pinched nerves in the knee to help alleviate pressure and reduce pain.
- Unloader knee brace. This type of knee brace helps to limit the side-to-side movement of the knee, and puts pressure on the thigh bones to alleviate knee pain.
When to Apply for Medicare
In order to apply for Medicare, you must meet the eligibility requirements, and you must enroll during a particular enrollment period.
To be eligible for Medicare:
- You are turning 65 or have a qualifying disability.
- You or your spouse worked and paid Medicare taxes for at least 10 years.
- You are a U.S. citizen or permanent legal resident who has lived in the U.S. for at least five years.
- You are receiving Social Security or RRB benefits, or have worked long enough to be eligible for those benefits but are not collecting them yet.
Medicare Enrollment Periods
Depending on your circumstances, there are a few times per year when you can apply for Medicare.
Initial Enrollment Period
If you’re eligible for Medicare when you turn 65, you are able to sign up during your Initial Enrollment Period. This is a 7-month period surrounding your birthday, including the three months before the month you turn 65, the month you turn 65, and the three months after the month you turn 65.
Special Enrollment Period (SEP)
If you don’t enroll in Part A or B during your Initial Enrollment Period, you may have an opportunity to enroll during a Special Enrollment Period. However, you must meet certain requirements to be eligible, such as if you’re covered under a group health plan based on current employment.
General Enrollment Period (GEP)
If you don’t enroll when you’re first eligible, and you don’t qualify for an SEP, you can still enroll during the Medicare General Enrollment Period from January 1 through March 31.
How to Enroll
To enroll, you can:
- Apply online at www.ssa.gov
- Visit your local Social Security office
- Call Social Security
- Call the RRB (if you worked for a railroad)
You do not have to sign up for Medicare each year. However, you will have the opportunity each year to review your coverage and make changes to your plan, such as enrolling in a Part C (Medicare Advantage) plan or adding Part D drug coverage. To enroll in Part C or Part D, you must also actively enroll in those plans. You can do so in each of the enrollment periods listed above.
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