Does Medicare Pay for a Knee Replacement?

Medicare generally covers medically necessary knee replacement surgery, a common procedure performed to alleviate pain and improve mobility. Understanding Medicare’s role in funding this procedure, including potential costs and procedural requirements, is important for beneficiaries. This article explains how Medicare covers knee replacement, your financial responsibilities, and how your specific Medicare plan may influence coverage.

Medicare’s General Coverage for Knee Replacement

Medicare provides coverage for knee replacement surgery when a doctor determines it is medically necessary. This typically means other conservative treatments have not been effective, or the condition significantly limits daily activities. Both inpatient and outpatient procedures are covered, with the specific Medicare part responsible depending on the setting.

If the surgery requires an inpatient hospital stay, Medicare Part A (Hospital Insurance) covers associated costs. This includes the hospital stay, operating room use, necessary medications, general nursing care, and some rehabilitation services like physical therapy during the stay.

For surgeries performed in an outpatient setting, Medicare Part B (Medical Insurance) provides coverage. Part B also covers surgeon’s fees, anesthesia, diagnostic tests like X-rays or MRIs before surgery, and pre- and post-operative doctor visits, as well as outpatient physical therapy for recovery.

Understanding Your Financial Responsibility

Even with Medicare coverage, beneficiaries typically incur out-of-pocket costs for a knee replacement. For inpatient hospital stays covered by Part A, a deductible applies per benefit period. In 2025, this Part A deductible is $1,676, covering the first 60 days of inpatient care. If an inpatient stay extends beyond 60 days, a daily coinsurance of $419 applies for days 61-90 in 2025.

For services covered by Medicare Part B, such as surgeon fees and outpatient therapy, an annual deductible applies. In 2025, the Part B annual deductible is $257. After meeting this deductible, beneficiaries typically pay 20% of the Medicare-approved amount for most covered services. Original Medicare Part A and Part B generally have no yearly limit on out-of-pocket costs.

Some providers might not accept Medicare assignment, leading to potential excess charges when they bill more than the Medicare-approved amount. To help manage these expenses, many beneficiaries consider Medigap (Medicare Supplement Insurance) plans. These private plans can cover deductibles, coinsurance, and copayments that Original Medicare does not.

How Your Medicare Plan Affects Coverage

The type of Medicare plan you have significantly influences how your knee replacement is covered and your financial obligations. Original Medicare, comprised of Part A and Part B, allows you to choose any Medicare-approved doctor or hospital nationwide. Under Original Medicare, coverage directly follows the Part A and Part B rules for inpatient and outpatient services and associated costs.

Alternatively, Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. These plans must cover at least everything Original Medicare covers. However, they often have different rules regarding how you receive care, and they may have their own networks of doctors and hospitals.

Medicare Advantage plans frequently require referrals from a primary care doctor to see specialists or undergo procedures like knee replacement. Staying within the plan’s network is often necessary to ensure maximum coverage and minimize out-of-pocket costs. These plans typically have their own copayments, deductibles, and an annual out-of-pocket maximum, which can differ from Original Medicare. In 2025, the maximum out-of-pocket limit for in-network services in Medicare Advantage plans can be up to $9,350.

Navigating the Coverage Process

Securing Medicare coverage for a knee replacement involves several practical steps, beginning with a thorough medical evaluation. Your doctor will conduct diagnostic tests and determine if the surgery is medically necessary, often after other non-surgical treatments have been explored.

A critical step involves obtaining prior authorization or pre-approval from Medicare or your Medicare Advantage plan before the surgery. This ensures the procedure is deemed medically necessary and covered by your plan, preventing unexpected financial burdens. Confirming that your chosen hospital, surgeon, and other medical providers are Medicare-approved or part of your Medicare Advantage plan’s network is also essential.

Following the surgery, Medicare also covers medically necessary post-operative care. This can include an inpatient stay in a skilled nursing facility if required for intensive rehabilitation, typically covered under Part A for up to 100 days under specific conditions. Outpatient physical therapy and home health services, such as skilled nursing care or physical therapy provided in your home, are generally covered by Part B if ordered by your physician.