Does Medicare Cover Knee Replacements?

Medicare helps beneficiaries manage healthcare needs, including coverage for complex medical procedures like knee replacement surgery. Understanding the conditions and financial aspects of this coverage is important for individuals considering this surgery.

Understanding Medicare Coverage Components

Medicare is structured into different parts, each covering distinct types of medical services. Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance).

Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. For a knee replacement, Part A covers costs associated with an inpatient hospital admission, including the operating room, nursing care, and medications during the hospital stay.

Medicare Part B covers medically necessary doctor’s services, outpatient care, durable medical equipment, and certain preventive services. For knee replacement, Part B covers surgeon fees, anesthesia, outpatient diagnostic tests, and physical therapy before and after surgery.

Beyond Original Medicare, individuals can choose Medicare Advantage Plans (Part C). These plans are offered by private companies approved by Medicare and provide all benefits of Part A and Part B, often including additional benefits like prescription drug coverage. Medicare Advantage plans must cover at least what Original Medicare covers for knee replacements.

Medicare Supplement Insurance, or Medigap policies, are private insurance plans that help pay some of the out-of-pocket costs associated with Original Medicare. These policies can assist with deductibles, coinsurance, and copayments, reducing a beneficiary’s financial responsibility.

Criteria for Knee Replacement Coverage

Medicare covers knee replacement surgery when a healthcare provider deems it medically necessary. This determination occurs after conservative treatments (e.g., medication, injections, physical therapy) have not provided sufficient relief for severe pain or functional limitations. Evidence of advanced joint disease, often confirmed through diagnostic imaging like X-rays, is also required.

Before surgery, Part B covers physician consultations and diagnostic tests like X-rays and MRIs to assess the knee joint. During surgery, if performed in an inpatient setting, Medicare Part A covers the hospital stay, including the procedure, anesthesia, a semi-private room, meals, nursing services, and necessary drugs and supplies. If performed on an outpatient basis, Medicare Part B covers the procedure.

Post-surgery, Medicare Part B covers rehabilitation services like physical therapy and occupational therapy, whether outpatient or in a skilled nursing facility after an inpatient hospital stay. Part B may also cover durable medical equipment (e.g., walkers, crutches, CPM machine) when prescribed by a doctor for home use during recovery. All care must be received from Medicare-approved doctors and facilities.

Patient Financial Responsibilities

Even with Medicare coverage, beneficiaries incur out-of-pocket costs for a knee replacement. For Original Medicare, these costs include deductibles and coinsurance payments, which change annually.

For inpatient hospital stays covered by Part A, the deductible for 2025 is $1,676 per benefit period. A benefit period begins the day a beneficiary is admitted to a hospital or skilled nursing facility and ends when they have not received inpatient care for 60 consecutive days. For extended inpatient hospital stays beyond 60 days, a daily coinsurance of $419 applies for days 61-90, increasing to $838 per day for lifetime reserve days from day 91 onward. For skilled nursing facility care, there is no coinsurance for the first 20 days, but it is $209.50 per day for days 21-100 in 2025.

For services covered under Part B (e.g., doctor’s visits, outpatient surgery, physical therapy), beneficiaries are responsible for an annual deductible of $257 in 2025. After meeting this deductible, Medicare generally pays 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance.

Medicare Advantage plans (Part C) have varying cost-sharing structures, typically involving copayments for doctor visits and hospital stays. These plans also include an annual out-of-pocket maximum of $9,350 for in-network costs in 2025, providing a ceiling for annual medical expenses. Medigap policies can help cover some or all of the deductibles and coinsurance amounts Original Medicare does not pay, reducing a beneficiary’s out-of-pocket burden.

Steps for Receiving Covered Care

Receiving a Medicare-covered knee replacement involves several steps, beginning with an initial consultation. Confirm the doctor accepts Medicare assignment, meaning they accept the Medicare-approved amount as full payment. The doctor will assess symptoms and provide a diagnosis.

Medicare requires non-surgical treatments to be attempted and proven ineffective before approving knee replacement surgery. This involves a period of conservative management. Once non-surgical options are exhausted, a referral to an orthopedic surgeon is next.

Many procedures, especially with Medicare Advantage plans, may require pre-authorization before surgery. This involves the doctor’s office submitting documentation to Medicare or the Medicare Advantage plan to demonstrate medical necessity. Original Medicare has fewer prior authorization requirements, but some services or equipment might still need approval.

After obtaining necessary approvals, schedule the surgery and hospital stay. Plan for post-operative care, including physical therapy or skilled nursing facility admission for rehabilitation. Verify these post-operative care providers also accept Medicare.

Following surgery, adhere to scheduled follow-up appointments with the surgeon and therapists. If coverage for a service is denied, beneficiaries have the right to appeal. The denial letter provides instructions on how to initiate this process.