Does Medicare Pay for Hip Replacement Surgery?
Explore Medicare's role in covering hip replacement. Get clear insights into coverage requirements, financial responsibilities, and plan variations.
Hip replacement surgery is a common medical procedure designed to alleviate pain and improve mobility for individuals with severe hip joint damage. Medicare, the federal health insurance program for people aged 65 or older and certain younger individuals with disabilities, covers costs associated with this surgery. This article clarifies Medicare’s coverage details, associated costs, and how different Medicare plans approach hip replacement.
Medicare Parts and Coverage
Original Medicare covers medically necessary hip replacement surgery. For coverage to apply, a healthcare provider must determine that the surgery is necessary due to conditions like severe arthritis or injury, and that less invasive treatments have not been effective.
Medicare Part A, Hospital Insurance, covers inpatient hospital stays, including the surgery, facility costs, and related services if an individual is admitted as an inpatient. This coverage applies when the procedure is performed in a Medicare-approved hospital. Part A also extends to care in a skilled nursing facility for rehabilitation, if medically required after the hospital stay.
Medicare Part B, Medical Insurance, covers services from doctors and other healthcare providers, as well as outpatient care. This includes the surgeon’s fees, anesthesiologist’s services, and other physician services received during the surgery. Part B also covers durable medical equipment, such as crutches or walkers, if prescribed by a doctor, and outpatient physical therapy needed for recovery.
Costs for Hip Replacement
Original Medicare beneficiaries are responsible for out-of-pocket costs for hip replacement surgery. For Medicare Part A, an inpatient hospital deductible of $1,676 applies for each benefit period in 2025. A benefit period begins the day an individual is admitted as an inpatient to a hospital or skilled nursing facility and ends after they have not received inpatient hospital or skilled nursing care for 60 consecutive days.
Beyond the deductible, Part A has coinsurance for extended inpatient stays. If a hospital stay extends beyond 60 days within a benefit period, a daily coinsurance of $419 applies for days 61 through 90 in 2025. For days 91 and beyond, individuals use their lifetime reserve days, which are 60 non-renewable days with a daily coinsurance of $838 in 2025.
Medicare Part B also has out-of-pocket expenses. Beneficiaries must meet an annual deductible of $257 in 2025 before Part B begins to pay its share. After the deductible is met, individuals pay 20% of the Medicare-approved amount for most doctor’s services, outpatient therapy, and durable medical equipment. Some beneficiaries choose to purchase Medicare Supplement Insurance (Medigap plans) to help cover these out-of-pocket expenses.
Medicare Advantage Plans and Hip Replacement
Medicare Advantage Plans (Part C) are offered by private companies as an alternative to Original Medicare. These plans must cover all services Original Medicare Part A and Part B cover, including medically necessary hip replacement surgery.
While Medicare Advantage plans provide the same baseline coverage, their cost-sharing structures can differ significantly from Original Medicare. These plans may have varying deductibles, copayments, and coinsurance amounts for services like hospital stays, doctor visits, and rehabilitation. Individuals should review their specific plan’s details to understand their potential financial responsibilities.
Most Medicare Advantage plans use provider networks, meaning beneficiaries must receive care from in-network providers for maximum coverage. Seeking care outside the network results in higher out-of-pocket costs. Many Medicare Advantage plans also require prior authorization for certain procedures, including hip replacement surgery.