Does Medicare Cover Orthopedic Doctors?

Medicare provides healthcare coverage for millions of Americans, primarily those aged 65 or older and certain younger individuals with disabilities. This federal health insurance program helps beneficiaries access a wide range of medical services. Orthopedic care, which addresses conditions affecting bones, joints, muscles, ligaments, and tendons, is generally covered under Medicare. Understanding this coverage is important for managing healthcare needs and associated costs.

Original Medicare and Orthopedic Services

Original Medicare, comprising Part A (Hospital Insurance) and Part B (Medical Insurance), provides comprehensive coverage for medically necessary orthopedic services. Medicare Part B covers a broad array of outpatient orthopedic services. This includes doctor visits, diagnostic tests such as X-rays, MRIs, and CT scans, and durable medical equipment (DME) like braces, crutches, walkers, and wheelchairs, prescribed by an orthopedic doctor. Physical therapy and occupational therapy, when ordered by a physician, are also covered outpatient services. Medicare Part B generally pays 80% of the Medicare-approved amount for these services after the annual deductible is met.

Medicare Part A primarily covers inpatient orthopedic care. This includes hospital stays for major surgical procedures such as joint replacements (e.g., hip or knee replacement), spinal surgeries, or complex fracture repairs. Part A also covers care in a skilled nursing facility (SNF) for rehabilitation after a qualifying hospital stay. This inpatient coverage extends to services like a semi-private room, meals, general nursing, and prescription medications administered during the hospital stay.

Understanding Your Costs with Original Medicare

While Original Medicare covers many orthopedic services, beneficiaries are responsible for out-of-pocket costs, including deductibles and coinsurance. For Part B services, an annual deductible must be met before Medicare begins to pay its share. In 2025, the annual Part B deductible is $257. After this deductible is satisfied, beneficiaries typically pay 20% of the Medicare-approved amount for most Part B services. There is no annual limit on this 20% coinsurance under Original Medicare.

For inpatient hospital stays covered by Part A, a deductible applies per benefit period. In 2025, the Part A deductible is $1,676 for each benefit period. A benefit period begins the day a patient is admitted as an inpatient and ends when they have not received inpatient hospital care for 60 consecutive days. If an inpatient stay extends beyond 60 days within a benefit period, a daily coinsurance amount applies. For 2025, this coinsurance is $419 per day for days 61 through 90, and $838 per day for lifetime reserve days, which are limited to 60 days over a beneficiary’s lifetime.

Orthopedic Care with Medicare Advantage Plans

Medicare Advantage Plans (Medicare Part C) offer an alternative way to receive Medicare benefits. These plans are provided by private insurance companies approved by Medicare and must cover at least all services Original Medicare covers. These plans often operate with their own networks of doctors, specialists, and hospitals. Beneficiaries may need referrals for specialists or certain procedures, depending on the plan type. Out-of-pocket costs, such as copayments, deductibles, and coinsurance, can differ from Original Medicare and vary among individual plans.

Medicare Advantage plans have an annual out-of-pocket maximum. In 2025, this maximum can be up to $9,350 for in-network services, though many plans set lower limits. Once this annual limit is reached, the plan pays 100% of the costs for covered services for the remainder of the year.

Strategies to Reduce Orthopedic Costs

Understanding strategies to supplement coverage can help manage orthopedic care costs under Medicare. Medicare Supplement Insurance (Medigap policies) can reduce out-of-pocket costs for those with Original Medicare. These private policies pay some costs Original Medicare does not cover, such as Part A and Part B deductibles, copayments, and coinsurance for orthopedic services. Medigap policies only work with Original Medicare and cannot be used with Medicare Advantage plans.

Confirming that an orthopedic doctor or facility accepts Medicare assignment or participates in a specific Medicare Advantage plan is important. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment, limiting what they can bill beneficiaries to the deductible and coinsurance. If a provider does not accept assignment, they may charge more than the Medicare-approved amount, leading to higher out-of-pocket costs.

Preventive care also helps reduce long-term orthopedic costs by promoting bone and joint health. Medicare Part B covers preventive services, such as bone mass measurements for individuals at risk of osteoporosis, which can help detect issues early. Utilizing these screenings and maintaining a healthy lifestyle may help prevent conditions that require extensive orthopedic interventions.