Does Medicare Cover Knee Replacement Surgery?
Key Takeaways
- A full knee replacement usually requires a short hospital stay.
- If you have Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). , your inpatient surgery will be covered by Part A.
- If you’re on Original Medicare and have knee replacement as an outpatient, Part B will cover it.
- A Medicare AdvantageA Medicare Advantage (Medicare Part C) plan is offered by a private insurance carrier to substitute for Original Medicare (Parts A and B). A Medicare Advantage plan must at least match the coverage you would receive from Original Medicare and may include additional benefits. Details vary by plan, and plan availability depends on your ZIP code. plan must at least match the knee replacement surgery coverage you’d receive from Original Medicare.
- You’ll need Medicare Part D prescription drug coverage for the cost of pain medication and other drugs required after surgery.
Knee replacement surgery is a common procedure among men and women over age 65. According to Harvard Women’s Health Watch, over 790,000 Americans receive this surgery annually. If your doctor has recommended a total knee replacement (also referred to as a total knee arthroplasty) you have probably been living with knee pain that disrupts your quality of life.
Original Medicare, the federally administered public health insurance program for U.S. adults who are over 65 or have certain disabilities, covers knee replacement surgery. Medicare Advantage plans, which are offered by private insurance carriers to substitute for Original Medicare, must at least match this coverage.
A total knee replacement is usually done on an inpatient basis. After surgery, you can expect to spend three to five days in the hospital.
Some people who have this surgery will get discharged directly from the hospital into an inpatient rehabilitation facility. This will be determined by your doctor. Other patients go home from the hospital and work with a physical therapist daily or several times a week. Either way, you can expect full recovery to take one to three months. During that time, you may continue to require the use of a cane or walker. You may also need the use of prescription pain medication for a period of time after surgery.
In some instances, your doctor may recommend partial, rather than full knee replacement. This procedure is referred to as a minimally invasive partial knee replacement, or “mini knee.” The main difference between a full knee replacement and a “mini knee” is the size of the incision made during surgery. The technique used to expose the knee joint is also less invasive. Your hospital stay will be of a similar duration for both procedures. Your recovery period and post-operative pain level may be lessened if you have a “mini knee.” Both surgeries require post-op physical rehabilitative services.
Will Medicare Pay for a Total Knee Replacement?
Your Medicare coverage can help to pay for knee replacement surgery.
Original Medicare (Part A and Part B)
The Medicare criteria for covering total knee replacement is that your doctor deems it medically necessary and that you have the surgery at a Medicare-approved facility.
Total knee replacement is usually done on an inpatient basis. That means your surgery will be covered under Medicare Part A, which is hospital insurance.
If your doctor determines you should have knee replacement done as an outpatient, it will be covered by Medicare Part B, which is medical insurance.
Medicare Part A will cover the cost of any inpatient rehabilitation you need it post-surgery. Outpatient physical therapy and follow-up visits with your surgeon will be covered under Part B.
If you need assistive equipment such as a cane after surgery, Part B will cover that cost. Canes, crutches and walkers are all examples of covered durable medical equipment. You will need to buy or rent the equipment that is prescribed for you from a Medicare-approved provider. Typically, the hospital where you have your knee replacement done will discharge you with the equipment you need.
If in addition to Original Medicare you can enroll in a Medicare Supplement Plan (Medigap) from a private insurance carrier. A Medigap plan will cover some of the out-of-pocket costs that Original Medicare doesn’t pay for a knee replacement. The type of plan you choose will determine the extent of coverage.
Original Medicare doesn’t cover most prescription drugs that you take outside of a medical setting. You will need a Medicare Part D (prescription drug) plan to cover any medications you’re prescribed after the procedure. For example, you may need drugs to manage pain and reduce the risks of infection or blood clots, including deep vein thrombosis.
Medicare Advantage (Part C)
If you have a Medicare Advantage plan instead of Original Medicare, it will cover the costs of a total knee replacement, although your out-of-pocket costs may be different.
Part C plans must at least cover everything that Original Medicare does, including inpatient rehabilitation, physical therapy, doctors’ visits. and durable medical equipment. Your plan may offer additional benefits, but you will need to visit doctors and hospitals that are in your provider network to get the most from your coverage.
Medicare Advantage Prescription Drug (MAPD) plans include Part D coverage. An MAPD plan will cover pain medication and other drugs you need post-surgery.
You cannot purchase a Medigap plan if you have Part C.
We're here to help you choose the ideal plan.
Average Out-of-Pocket Cost for Knee Replacement
According to Medicare, the exact costs for any surgical procedure may be hard to calculate exactly ahead of time. However, you can estimate your out-of-pocket costs.
If you have Original Medicare, you will have an out-of-pocket deductible you will have to meet for Part A. The day you go into the hospital for knee replacement surgery will be the first day of your benefit period. If your hospital stay doesn’t exceed 60 days, you will have $0 coinsurance costs. Occasionally, complications arise after surgery. If you remain in the hospital for any reason, your costs per benefit period will stay the same.
If you are discharged into a rehabilitative facility directly from the hospital (or are admitted to a rehab facility within 60 days of your first day in the hospital, you won’t have to pay an additional deductible for your care. If your total stay exceeds 60 days, you may be responsible for daily coinsurance. However, most knee replacement patients are discharged long before this time period begins.
What’s Included in Knee Replacement Costs?
Medicare will pay for 80% of the Medicare-approved cost of all outpatient services covered under Part B after you meet the annual deductible. This includes outpatient surgery. If you have Medigap, your plan may cover some or all of the remaining 20%.
If you have Medicare Advantage, your insurance carrier can tell you what your costs will be for your surgery, hospital stay and post-operative care.
What Equipment Does Medicare Cover for Knee Replacement?
Medicare covers durable medical equipment (DME) that is medically necessary and prescribed for your use at home. After knee surgery, this equipment may be referred to as assistive devices. You will use your assistive devices during outpatient physical therapy for gait training (supervised walking). You will also use them to enhance your mobility and keep you safe from falling during the recuperation process.
You may be required to rent or buy the DME you need. In some instances, it may be up to you whether you rent or buy.
If you have Original Medicare, Part B will cover 80% of the Medicare-approved cost of this equipment. If you have Part C, your out-of-pocket costs will be determined by your plan.
You may be prescribed some or all of these assistive devices:
- Cane
- Crutches
- Walker
My Medicare coverage doesn’t address all of my needs.
Alternatives to Knee Surgery
Many people turn to knee surgery after other treatments have ceased to provide enough relief. These include taking arthritis medication and doing physical therapy, which are both covered by Medicare.
If you don’t feel ready for surgery, there are alternatives to knee surgery that Medicare typically covers. You and your doctor can determine which is best for you.
Alternative treatments include:
- Genicular nerve block – This non-surgical treatment blocks the genicular nerves, reducing or halting pain. It takes around 10 minutes to perform and is done on an outpatient basis.
- Viscosupplementation – Your doctor will inject hyaluronic acid into the knee joint, lubricating the area between two bones. This outpatient procedure reduces pain and slows the progression of arthritis.
Sources
- Is it time for a knee replacement? Harvard Health Publishing.
- Inpatient Rehabilitation Care. Medicare.gov.
- Total Knee Replacement: A Patient’s Guide. Washington.edu.
- Minimally Invasive Total Knee Replacement. OrthoInfo.org.
- Surgery. Medicare.gov.