Does Medicare Cover Hip Replacement Surgery?

Medicare generally covers medically necessary hip replacement surgery. The extent of this coverage, however, depends on specific Medicare parts and certain conditions being met. Understanding these details is important for individuals considering hip replacement surgery.

Medicare Parts Involved in Coverage

Different parts of Medicare contribute to covering the various aspects of hip replacement surgery.

Medicare Part A, Hospital Insurance, primarily covers inpatient hospital stays. This includes the costs associated with the surgery itself when performed in a hospital setting, along with necessary services like nursing care, meals, and other hospital supplies during the inpatient stay.

Medicare Part B, Medical Insurance, covers services provided by doctors and other healthcare providers. This includes the surgeon’s fees, anesthesiologist’s services, and other physician services received during the surgery and hospital stay. Part B also covers outpatient services, such as pre-operative consultations, diagnostic tests like X-rays and MRIs, and durable medical equipment (DME) if prescribed for use after the surgery.

Medicare Part C, Medicare Advantage Plans, offers an alternative way to receive Medicare benefits through private insurance companies. These plans are required to provide at least the same level of coverage as Original Medicare (Parts A and B). Medicare Advantage plans may have different rules, provider networks, and cost-sharing structures, such as varying deductibles, copayments, and coinsurance amounts. Individuals enrolled in a Medicare Advantage plan should contact their specific plan administrator to understand their hip replacement coverage details.

Eligibility for Coverage

Medicare coverage for hip replacement surgery is contingent upon meeting specific eligibility criteria. The surgery must be deemed medically necessary by a doctor who accepts Medicare assignment. Medical necessity typically means that the surgery is required to diagnose or treat an illness, injury, or to improve the functioning of a malformed body part. Common indicators of medical necessity for hip replacement include severe pain that limits daily activities, significantly restricted mobility, or the failure of less invasive, conservative treatments.

The procedure must be performed in a facility approved by Medicare, such as a Medicare-certified hospital or ambulatory surgical center. These facilities adhere to federal health and safety standards to ensure patient care quality. Additionally, a physician’s order for the surgery is required, confirming the medical necessity and outlining the treatment plan.

Costs and Patient Responsibility

While Medicare provides substantial coverage for hip replacement surgery, patients are responsible for certain out-of-pocket costs.

For services covered under Medicare Part A, beneficiaries are responsible for a deductible of $1,676 per benefit period in 2025. For hospital stays exceeding 60 days within a benefit period, a daily coinsurance applies, which is $419 per day for days 61-90 and $838 per day for lifetime reserve days from day 91 onward in 2025.

Under Medicare Part B, beneficiaries must meet an annual deductible, which is $257 in 2025. After this deductible is satisfied, patients typically pay 20% of the Medicare-approved amount for most doctor’s services and outpatient care. There is no annual out-of-pocket maximum under Original Medicare. Medicare Advantage plans, however, have different cost-sharing structures and typically include an annual out-of-pocket maximum, which can be as high as $9,350 for in-network services in 2025. To help cover some of the out-of-pocket costs associated with Original Medicare, beneficiaries may opt for a Medigap (Medicare Supplement Insurance) policy, which can assist with deductibles, coinsurance, and copayments.

Related Services and Post-Operative Care

Medicare covers a range of services related to hip replacement surgery. Prior to surgery, coverage includes necessary pre-operative care such as consultations with specialists, diagnostic tests like X-rays and MRIs to assess the hip joint, and other medical assessments to ensure the patient is a suitable candidate for surgery. These preparatory services fall under Medicare Part B coverage.

The inpatient hospital stay for the surgery is covered by Medicare Part A, encompassing the operating room, recovery room, and the duration of the hospital admission. Following hospital discharge, if medically necessary, Medicare Part A may cover a short-term stay in a skilled nursing facility (SNF) for continued recovery and rehabilitation. This SNF coverage is typically for up to 100 days per benefit period, with a daily coinsurance of $209.50 for days 21-100 in 2025.

Post-operative rehabilitation is also covered, with Medicare Part B providing coverage for outpatient physical therapy and occupational therapy sessions. These therapies are crucial for regaining strength, mobility, and function after surgery. Additionally, Medicare Part B covers durable medical equipment (DME) prescribed by a doctor, such as walkers, crutches, or hospital beds, which may be needed to aid in recovery and mobility at home.