Does Medicare cover knee replacement surgery?
Did you know that more than 790,000 knee replacement surgeries are performed in the U.S. every year? The most common reason you might need a knee replacement is due to osteoarthritis, a degenerative joint disease. Other reasons include knee damage or breakage.
While it's a common procedure, it’s still an intensive surgery that can be costly.
Thankfully, Medicare helps with the cost of a knee replacement surgery. If you have a Medigap plan, you’ll owe very little for the surgery. In fact, my mother had to have knee replacement surgery. Because Original Medicare doesn’t cover 20% of costs for covered services, she would have had to pay $8,000 out-of-pocket if she didn’t have Medigap Plan G. Instead, she reached the 2023 Medicare Part B deductible of $226 and didn’t have to pay anything else.
Coverage depends on a few factors like the Medicare coverage you have, the specific type of surgery you get, and where the operation is performed. Read on to learn what Medicare can and can’t cover when it comes to knee replacement.
Key takeaways:
Together, Original Medicare and a Medigap plan cover almost all of the cost of a knee replacement surgery.
Medicare Advantage plans also cover knee replacement surgeries, but pricing structures vary from plan to plan. Your out-of-pocket costs, including deductibles, copays, and coinsurance, will depend on your policy.
After a knee replacement surgery, Medicare also covers recovery costs. You can get coverage for prescription drugs, mobility aids, and a few days in a skilled nursing home.
How much a knee replacement surgery costs
Without insurance, knee replacements can cost up to $19,995 for a total replacement and $18,995 for a partial knee replacement. The cost is for services, including:
X-rays and other imaging of the joint
Materials and the operation
Anesthesia
Rehabilitation in the hospital during recovery
This price can vary depending on your location, health facility, device, pre-existing conditions, and specific surgical procedure.
Does Medicare cover knee replacement surgery?
Medicare does cover knee replacement surgery if it’s considered medically necessary. What you pay out-of-pocket is determined by the specific Medicare coverage you have. Let’s dive into what Original Medicare, Medicare Supplement, and Medicare Advantage each cover.
Original Medicare Part A and Part B
Medicare Part A covers inpatient hospital costs and Part B covers outpatient treatments, procedures, and surgeries. In most situations, Medicare Part B pays for a knee replacement surgery. Original Medicare only covers 80% of surgery costs. You’re responsible for the remaining 20%, unless you have a Medigap plan that helps fill in the gaps in coverage.
Medigap coverage for knee replacements
Medigap was originally designed to cover the gaps left by Original Medicare. Also called Medicare Supplement, the plans pay for things like deductibles, coinsurance, and copayments. Once you reach your Medicare Part B deductible (which is $240 in 2024) for the knee replacement surgery, your Medigap plan will help cover your additional out-of-pocket costs.
For example, when my mom had to get her knee replacement surgery, her Part B deductible was $226. With her Medigap Plan G, she did not have to pay anything once she met her deductible.
Medicare Advantage coverage for knee replacements
By law, Medicare Advantage plans, a bundled, all-inclusive option for enrollees, must cover the same services and treatments as Original Medicare. This means that Medicare Advantage plans would help with the costs of a knee replacement surgery. However, the out-of-pocket costs of the procedure would depend entirely on your specific policy. Pricing structures vary — deductibles, coinsurance, and copays are different between different plans. If you have a Medicare Advantage plan, it’s important to contact your insurance carrier and doctor’s billing department to understand what you could pay for a knee replacement surgery.
Medicare coverage for knee replacement after surgery
After the knee surgery, you’ll need prescriptions for rehabilitation, pain relief, and to reduce the risk of blood clots or infection. Medicare Part D covers the prescription drugs you’ll need following a surgery.
Depending on the level of care you need after surgery, Medicare Part B covers walking aids.
If you have more questions about your Medicare coverage, our licensed Medicare Advisors are eager to help. Whether you want assistance with finding a cost-effective healthcare plan that caters to your needs or clarification on your existing coverage. Give us a call at (855)-900-2427 to get help understanding and using your Medicare plan.