How Much Does Medicare Pay for a Hip Replacement?

Hip replacement surgery is a common procedure that can significantly improve quality of life for individuals experiencing severe hip pain or mobility issues. Understanding how Medicare contributes to the costs associated with this surgery is important for beneficiaries. While Medicare often covers a substantial portion of the expenses, patients typically remain responsible for certain out-of-pocket amounts.

Understanding Medicare Coverage for Hip Replacement

Medicare coverage for a hip replacement largely depends on whether the procedure is performed on an inpatient or outpatient basis. Medically necessary hip replacement surgery, along with associated rehabilitation and equipment, is generally covered by Medicare.

Medicare Part A, known as Hospital Insurance, covers inpatient hospital stays. Part A covers a semi-private room, meals, general nursing care, and medications administered during the hospital stay. Part A also covers limited stays in a skilled nursing facility if needed for recovery after the hospital discharge.

Medicare Part B, or Medical Insurance, covers services provided by doctors, such as the surgeon and anesthesiologist. It also covers outpatient physical and occupational therapy necessary for recovery, along with durable medical equipment. If the hip replacement is performed in an outpatient surgical facility, Part B covers these associated costs.

Medicare Part C, known as Medicare Advantage plans, offers an alternative to Original Medicare (Parts A and B) and is provided by private insurance companies. These plans are required to cover at least the same services as Original Medicare, including hip replacement. However, Medicare Advantage plans often have different cost-sharing rules, network restrictions, and may offer additional benefits.

Medicare Part D, Prescription Drug Coverage, may cover medications prescribed after the surgery, such as pain relievers or blood thinners. Beneficiaries with a Medicare Advantage plan that includes prescription drug coverage typically have these medications covered under that plan.

Your Out-of-Pocket Costs

Beneficiaries are responsible for out-of-pocket costs for a hip replacement with Medicare. For inpatient hospital stays covered by Medicare Part A, a deductible of $1,676 applies per benefit period in 2025.

Should a hospital stay extend beyond 60 days within a benefit period, a daily coinsurance amount applies. For days 61 through 90, the coinsurance is $419 per day, and for lifetime reserve days (beyond day 90), it is $838 per day. For a skilled nursing facility stay, the daily coinsurance for days 21 through 100 is $209.50.

For services covered under Medicare Part B, an annual deductible of $257 applies in 2025. After the deductible is satisfied, beneficiaries generally pay 20% of the Medicare-approved amount for most doctor services and outpatient care.

Medigap, or Medicare Supplement Insurance plans, can help reduce these out-of-pocket expenses by covering deductibles, coinsurance, and copayments. These plans are purchased separately and have their own premiums. Medigap plans can provide more predictable costs by covering many of the gaps in Original Medicare.

Out-of-pocket costs differ with Medicare Advantage Plans (Part C) with their own deductibles, copayments, and coinsurance amounts that vary by plan. Medicare Advantage plans also include an annual out-of-pocket maximum, which limits how much a beneficiary will pay for covered services in a year. In 2025, the maximum out-of-pocket limit for in-network services in Medicare Advantage plans can be up to $9,350.

Factors Influencing the Total Cost

Several factors can influence the overall cost of a hip replacement, even with Medicare coverage. Geographic location significantly impacts costs, with variations across states, cities, and metropolitan areas due to differing healthcare market dynamics and local cost of living.

The type of facility chosen for the surgery also affects the total expense. Costs can differ between large academic medical centers and smaller community hospitals, or if the procedure is performed in an ambulatory surgical center versus an inpatient hospital setting.

Surgeon’s fees, anesthesia fees, and the cost of the implant itself are additional variables. While implant costs are typically part of the facility fee, the specific type and material of the prosthetic can indirectly influence the overall hospital charge. The experience and reputation of the surgeon can also play a role in their fees.

Post-surgical needs, such as rehabilitation, contribute to the total cost. This can include physical therapy sessions, skilled nursing facility stays, or home health care.

Complications arising during or after surgery can substantially increase expenses due to extended hospital stays, additional procedures, or prolonged recovery periods. Pre-existing medical conditions can also influence the complexity and duration of care, potentially leading to higher costs.

Ensuring Coverage and Managing the Billing Process

To ensure Medicare coverage for a hip replacement, choose healthcare providers who accept Medicare assignment. This means the provider agrees to accept the Medicare-approved amount as full payment, which typically results in lower out-of-pocket costs. Providers who accept assignment also bill Medicare directly, simplifying the process.

For some procedures or with Medicare Advantage plans, prior authorization or pre-approval may be required before the surgery. Confirm any such requirements with your Medicare Advantage plan or healthcare provider before the procedure to prevent unexpected denials.

After services are rendered, beneficiaries will receive an Explanation of Benefits (EOB) from Medicare, or a similar statement from their Medicare Advantage plan. An EOB is not a bill, but details what Medicare paid and your responsibility. It is important to review these statements carefully and compare them against any actual bills received.

Patients will often receive separate bills from the hospital, surgeon, anesthesiologist, and other providers involved in their care. Should any discrepancies arise regarding these bills, contact the provider’s billing department or Medicare for clarification.

Beneficiaries have the right to appeal Medicare decisions if coverage for a service is denied or if they disagree with the amount paid. The appeals process involves several levels, with instructions provided on the Explanation of Benefits or denial notice, allowing patients to seek a review of their coverage determination.