A full knee replacement usually requires a short hospital stay.
If you have Original Medicare , 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.
Medicare Advantage covers knee replacement surgery plus the rehabilitative services you’ll need afterwards.
Original Medicare generally won’t cover 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. If you’re on Medicare, you may be wondering if Medicare covers knee replacement and the extent of any coverage and out-of-pocket costs.
Medicare pays for knee replacement surgery. The out-of-pocket costs you incur will be determined by the type of plan you have:
Original Medicare (Part A and Part B)
Original Medicare covers knee replacement surgery. The Medicare criteria for total knee replacement is that your doctor deems it medically necessary, and that you have the surgery performed at a Medicare-approved facility.
Medicare total knee replacement is usually done on an inpatient basis. When it is done as an inpatient procedure, your surgery will be covered under Medicare Part A. Part A is the part of Medicare that covers inpatient healthcare.
If your doctor determines you should have knee replacement done as an outpatient, Medicare Part B will pay for it. Part B is the part of Medicare that covers outpatient healthcare.
Original Medicare will cover the cost of inpatient rehabilitation, should you need it post-surgery. This will be covered by Part A.
Physical therapy and follow-up visits with your surgeon will be covered under Part B.
If you need support such as a cane after surgery, Part B will cover that cost. Canes, crutches and walkers are all examples of covered durable medical equipment. To get Medicare coverage, you will need to buy or rent durable medical 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 have a Medicare Supplement Plan (Medigap), it will cover some of the out-of-pocket costs that Original Medicare doesn’t pay for a knee replacement. The letter plan you have will determine the type and extent of coverage you can expect.
Original Medicare doesn’t cover prescription drugs. If you have a standalone Part D (prescription drug) plan, it will cover your prescription medication needs, including pain medication that may be required after surgery.
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 will be different than those incurred with Original Medicare.
Part C plans cover everything that Original Medicare does, including inpatient rehabilitation, physical therapy, doctors visits and durable medical equipment.
Most Part C plans include Part D (prescription drug) coverage. With Part C, the drugs you need post-surgery, such as prescription pain medication, will be covered if your plan includes drug coverage. Other drugs that might be prescribed for you include those to reduce infection and the risk of blood clots, including deep vein thrombosis.
You cannot purchase a Medigap plan if you have Part C.
What Medicare benefits are available for knee surgery?
A total knee replacement is also referred to as a total knee arthroplasty. If your doctor has recommended this procedure to you, you have probably been living with knee pain that disrupts your quality of life.
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.
Medicare provides all these benefits for people who need a total knee replacement, provided that the procedure and services required for rehabilitation are determined to be medically necessary. This determination can be made by your doctor or surgeon if they are a Medicare-approved provider.
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.
Medicare provides all of these benefits for people who have a partial knee replacement, provided they meet the same criteria for being medically necessary that a full knee replacement does.
There is no Medicare knee replacement age limit for either procedure.
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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. This includes the surgery itself if it is done on an outpatient basis. If you have Medigap, your plan may cover some or all of the remaining 20%.
If you have Medicare Advantage, your plan can tell you what your deductible and coinsurance will be for your surgery, hospital stay and post-operative care. These vary from plan to plan, and are often lower than those incurred with Original Medicare.
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:
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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.