Does Medicare Cover Knee Replacement Surgery Costs?
If your doctor recommends knee replacement surgery, your first question is probably, “how much does a knee replacement cost?” Knee surgery cost depends on a number of factors, including where you live, where you have the surgery, whether you have any complications, and the type of care you’ll need after surgery.
Fortunately, if you have Medicare, the actual knee replacement cost you pay out-of-pocket is limited by rules governing Medicare Part A and Part B. Read on to learn more details about knee replacement cost under Medicare.
What’s included in knee replacement cost?
Knee replacement is a surgical procedure, and like all major surgeries, there are many factors that go into the total cost of the procedure. Here are some factors that contribute to knee replacement cost:
- Length of time in the operating room
- Type and amount of anesthesia
- X-rays during and after the procedure
- Medications to manage pain, prevent infection, and reduce the risk of blood clots
- Inpatient hospital days during your recovery
- Physical therapy services to help you exercise your knee
Under Original Medicare, Part A covers your inpatient stay for knee replacement once you meet your Part A deductible. The Mayo Clinic suggests that most people spend just a few days in the hospital after their surgery, so you generally should not have to worry about any Part A coinsurance amounts.
Although most people have knee replacement as an inpatient, in 2018, Medicare approved payment for outpatient knee replacements. If your doctor believes you are a candidate for outpatient surgery, your knee surgery cost would be covered under Part B. Part B may cover 80% of all allowable charges for knee replacement after you meet your Part B deductible.
What should I consider in knee surgery cost after I am discharged from the hospital?
You may be sent home with prescription medications to manage pain, and reduce the risk of blood clots or infection. You will probably have one or more follow-up appointments with your surgeon. You may also need physical therapy or other rehabilitation services for a few weeks after the procedure.
Although there is generally no coverage under Original Medicare for prescription medications you take at home, Part B typically pays 80% of allowable charges for all medically necessary doctor visits and physical or occupational therapy services you need after your surgery. Part B usually also generally covers durable medical equipment such as a cane or walker if your doctor orders one for you to use during your recovery. It’s a good idea to discuss your after-surgery care with your doctor so you know what to expect and can better plan for your out-of-pocket expenses.
In some cases, your doctor may recommend a brief stay in a skilled nursing facility after your knee replacement. In order to be eligible for Part A skilled nursing facility coverage, you must have a qualifying hospital stay of at least three days prior to your admission. If your stay is covered, you pay nothing for the first 20 days of skilled nursing facility care; there is a daily coinsurance amount applied to days 21 and beyond.
If you are considering an outpatient knee replacement surgery, be sure to talk to your doctor about what to expect during recovery, since you will not have a qualifying hospital stay for skilled nursing facility benefits. If you need skilled nursing care after outpatient knee replacement surgery, you may have to pay those costs out of pocket.
What other Medicare benefits are available for knee surgery cost?
A Medicare Supplement plan pays some or all of your out-of-pocket knee replacement costs under Part A and Part B, except for your premiums. Depending on the plan you choose, your Medicare Supplement Plan may cover your Part A and Part B deductibles and coinsurance amounts. Keep in mind, however, that Medicare Supplement Plans generally do not cover any out-of-pocket costs associated with prescription drugs not covered by Medicare.
Medicare Part D is how Medicare beneficiaries get prescription drug coverage. Medicare Advantage plans and stand-alone Medicare Part D Prescription Drug Plans are offered by private insurance companies, which means that plan benefits, deductibles, and cost-sharing structures may vary widely from plan to plan. Each plan may treat knee replacement cost and associated expenses a bit differently. Read your plan documents carefully before your procedure to help you estimate your out-of-pocket knee surgery cost.
If you are covered by a Medicare Part D Prescription Drug Plan, either as a complement to Original Medicare or as part of a Medicare Advantage plan, the medications you take at home are generally covered. You may have a deductible, copayment, or coinsurance amount for these medications.
Do you want to find a Medicare plan that can cover you if you have knee replacement? Just enter your zip code on this page to begin searching.