Does Medicare Pay for Rehab After Knee Replacement Surgery?

Knee replacement surgery often requires rehabilitation to restore mobility and strength. Medicare can cover these services, but the extent of coverage depends on specific conditions and the type of Medicare plan. This article details Medicare coverage for rehabilitation after knee replacement surgery, including covered services, eligibility, financial responsibilities, and how to access benefits.

Medicare Coverage for Rehabilitation Services

Medicare covers rehabilitation services through different parts of the program, depending on whether care is inpatient or outpatient. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Advantage plans, offered by private companies, must cover at least the same services as Original Medicare.

Medicare Part A covers inpatient rehabilitation care, typically provided in Skilled Nursing Facilities (SNFs) or Inpatient Rehabilitation Facilities (IRFs). These facilities offer intensive therapy and medical supervision. Part A coverage includes a semi-private room, meals, nursing care, medications, and therapy services like physical, occupational, and speech-language pathology.

Medicare Part B covers outpatient rehabilitation services, including physical, occupational, and speech-language pathology. These services are often received in a doctor’s office, outpatient clinic, or through home health agencies if the patient is homebound. Part B also covers durable medical equipment needed for recovery. Medicare Advantage (Part C) plans cover all services provided by Original Medicare, but may have different cost-sharing, network restrictions, or require referrals or prior authorization. Consult your specific plan for precise coverage.

Eligibility and Specific Criteria for Coverage

For Medicare to cover rehabilitation services after knee replacement surgery, certain conditions must be met. All services, whether inpatient or outpatient, must be medically necessary, meaning they are required to treat the illness or injury and are provided at an appropriate level of care.

A physician’s order and an established plan of care are required for covered rehabilitation services. This plan must be regularly reviewed and updated by healthcare professionals. Services must be received from Medicare-certified facilities or providers.

For Medicare Part A to cover skilled nursing facility (SNF) care, a qualifying inpatient hospital stay of at least three consecutive days is generally required before SNF admission. This prior hospital stay must be for a medically necessary inpatient admission. Part A covers up to 100 days of SNF care per benefit period, which begins when an individual is admitted as an inpatient and ends after 60 consecutive days without inpatient care.

For Part B services, a threshold exists for combined physical therapy and speech-language pathology services, and for occupational therapy services. For 2025, this threshold is $2,410 for each category. If costs exceed this, providers must attest that services remain medically necessary.

Understanding Your Financial Responsibility

Even with Medicare coverage, beneficiaries will have out-of-pocket costs for rehabilitation services, including deductibles, co-insurance, and co-payments. These vary based on the Medicare plan and services received.

For Medicare Part A, the inpatient hospital deductible for each benefit period is $1,676 in 2025. This deductible applies before Medicare pays for covered services. For skilled nursing facility (SNF) care under Part A, there is no co-insurance for the first 20 days within a benefit period. From day 21 through day 100, a daily co-insurance of $209.50 applies in 2025. After day 100, the beneficiary is responsible for all costs.

Medicare Part B services have an annual deductible of $257 in 2025. After this is met, beneficiaries typically pay 20% of the Medicare-approved amount for most outpatient services, including physical and occupational therapy. Original Medicare does not have an annual out-of-pocket maximum.

For beneficiaries with Medicare Advantage plans, out-of-pocket costs like co-pays, co-insurance, and deductibles may differ from Original Medicare. These plans often include an annual out-of-pocket maximum.

Accessing and Utilizing Your Medicare Rehab Benefits

Accessing Medicare-covered rehabilitation services after knee replacement surgery involves several steps. The treating physician prescribes and refers the patient to appropriate rehabilitation services, initiating the process.

When choosing a rehabilitation facility, such as a Skilled Nursing Facility or an outpatient therapy clinic, verify that the provider is Medicare-certified. Medicare’s “Care Compare” tool helps beneficiaries find and compare certified providers and facilities. Your type of Medicare plan (Original Medicare or Medicare Advantage) impacts network requirements, referral processes, and prior authorization needs.

If coverage for services is stopped or denied, beneficiaries have the right to appeal the decision. The appeals process allows for a review of the decision.