Does Medicare Cover Knee Replacement Cost?

Medicare generally covers the cost of knee replacement surgery, provided the procedure is medically necessary. This coverage extends to various aspects of the surgical process and subsequent recovery.

Understanding Original Medicare Coverage for Knee Replacement

Original Medicare, composed of Part A and Part B, covers different components of a knee replacement, based on whether the procedure is performed on an inpatient or outpatient basis. For coverage, a physician must deem the surgery medically necessary, if the knee condition significantly limits mobility or daily activities and other treatments have been ineffective.

Medicare Part A, Hospital Insurance, covers inpatient hospital stays for the knee replacement surgery. This includes costs for the hospital facility, such as a semi-private room, meals, general nursing care, and medications administered during the hospital stay. Part A also covers skilled nursing facility (SNF) care if required for recovery after a qualifying inpatient hospital stay, typically lasting at least three days. It further extends to some rehabilitation services provided while an inpatient.

Medicare Part B, Medical Insurance, covers services provided outside of an inpatient hospital admission. This includes surgeon and physician fees, pre-operative consultations, diagnostic tests like X-rays and MRIs, and post-operative care. If a knee replacement is performed as an outpatient procedure, Part B covers the surgery.

Part B also covers medically necessary outpatient physical therapy and occupational therapy, which are crucial for regaining strength and mobility. Durable medical equipment (DME), such as walkers or crutches, prescribed for use during recovery, also falls under Part B coverage.

Medicare Part D, which provides prescription drug coverage, helps cover necessary medications related to the recovery process. These can include pain medication, antibiotics, or blood thinners prescribed after discharge from the hospital. While Part A covers medications administered during an inpatient hospital stay, Part D addresses prescriptions filled at a pharmacy for use at home.

Patient Out-of-Pocket Costs with Original Medicare

Specific financial responsibilities exist when undergoing a knee replacement with Original Medicare. These costs include deductibles, coinsurance, and copayments, which can vary based on the services received and the length of care.

For Medicare Part A, the inpatient hospital deductible for 2025 is $1,676 per benefit period. A benefit period begins the day a patient is admitted as an inpatient and ends after 60 consecutive days without inpatient hospital or skilled nursing facility care. A patient might incur this deductible more than once in a year if multiple benefit periods occur.

Beyond the deductible, Part A has coinsurance charges for extended stays. For hospital inpatient stays in 2025, there is no coinsurance for days 1-60. For days 61 through 90, the coinsurance is $419 per day. If a stay extends further, lifetime reserve days can be used from day 91 onward, incurring a coinsurance of $838 per day, with a limit of 60 lifetime reserve days.

Skilled nursing facility (SNF) care also has specific coinsurance costs under Part A. For the first 20 days of SNF care in 2025, there is no coinsurance. For days 21 through 100, the daily coinsurance amount is $209.50. After 100 days in a skilled nursing facility within a benefit period, the patient is responsible for all costs.

Medicare Part B involves its own out-of-pocket expenses. The annual Part B deductible for 2025 is $257. Once this deductible is met, patients are responsible for a 20% coinsurance of the Medicare-approved amount for most covered services, including physician fees, outpatient therapy, and durable medical equipment. There is no annual limit on this 20% coinsurance under Original Medicare.

Costs associated with Medicare Part D for prescription drugs vary depending on the specific plan chosen. These plans have their own deductibles, which cannot exceed $590 in 2025. After the deductible, patients will pay copayments or coinsurance for their medications, with amounts varying by drug tier and plan design.

Medicare Advantage and Supplement Plans for Knee Replacement

Medicare Advantage Plans, also known as Part C, offer an alternative way to receive Medicare benefits. These plans are provided by private companies approved by Medicare and are required to cover all the benefits of Original Medicare (Parts A and B). For a knee replacement, a Medicare Advantage plan will cover the surgery and associated care, but out-of-pocket costs and coverage structure can differ significantly from Original Medicare.

Medicare Advantage plans often have their own network rules, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which may limit choices of doctors and hospitals. These plans also feature their own deductibles, copayments, and coinsurance amounts, which can vary widely between plans. Notably, Medicare Advantage plans include an annual out-of-pocket maximum, which caps the total amount a beneficiary pays for covered services in a year, a feature not present in Original Medicare.

Medicare Supplement Insurance, or Medigap plans, work differently by complementing Original Medicare rather than replacing it. These plans are sold by private companies and help cover some of the out-of-pocket costs that Original Medicare does not, such as deductibles, coinsurance, and copayments. For a knee replacement, a Medigap policy can significantly reduce a patient’s financial responsibility by covering a portion or all of the Part A and Part B cost-sharing amounts detailed previously.

Different Medigap plans, identified by letters (e.g., Plan F, Plan G), offer varying levels of coverage for these out-of-pocket expenses. For instance, some plans may cover the Part A deductible or the Part B coinsurance. Medigap plans only work with Original Medicare; they cannot be used with Medicare Advantage plans.