How Much Does Medicare Pay for a Knee Replacement?

Knee replacement surgery is a common procedure for many older adults experiencing significant knee pain and mobility issues. The prospect of such a surgery often brings questions about its financial implications. For individuals enrolled in Medicare, understanding how this federal health insurance program contributes to the costs of a knee replacement is important.

Medicare Coverage for Knee Replacement

Medicare provides comprehensive coverage for medically necessary knee replacement surgery through its different parts. The specific part of Medicare that covers your procedure depends on whether the surgery is performed on an inpatient or outpatient basis. Most knee replacements are typically performed in an inpatient setting, but outpatient options are increasingly available.

Medicare Part A, Hospital Insurance, covers inpatient hospital stays. This includes hospital facility costs like a semi-private room, meals, general nursing care, and necessary supplies and treatments. Part A also covers care in a skilled nursing facility (SNF) if needed after hospital discharge, along with some home health services.

Medicare Part B, Medical Insurance, covers professional services and outpatient care. This includes surgeon’s fees, anesthesia services, and doctor visits before and after surgery. Part B also covers durable medical equipment (DME), such as walkers or crutches. Physical therapy and rehabilitation services, whether in an outpatient clinic or during an outpatient hospital visit, are also covered under Part B.

Medicare Part C, Medicare Advantage plans, offer an alternative way to receive Medicare benefits. These plans are provided by private insurance companies approved by Medicare and must cover everything Original Medicare (Parts A and B) covers. They may have different cost-sharing requirements, network restrictions, and often include additional benefits. Review your specific Medicare Advantage plan details to understand its coverage for knee replacement surgery.

Medicare Part D, Prescription Drug Coverage, is a separate plan that covers the cost of prescription medications. While not directly covering the surgery, Part D is relevant for any medications prescribed before, during, or after your knee replacement, such as pain relievers or antibiotics. These plans are offered by private companies and vary in their formularies and cost-sharing structures.

Understanding Your Out-of-Pocket Costs

Even with Medicare coverage, beneficiaries are responsible for certain out-of-pocket costs, including deductibles, coinsurance, and copayments. Understanding these components is essential for managing healthcare expenses.

A deductible is the amount you must pay for covered healthcare services before Medicare begins to pay. For Medicare Part A, the inpatient hospital deductible in 2025 is $1,676 per benefit period. A benefit period begins the day you are admitted as an inpatient and ends after you have been out of the hospital or skilled nursing facility for 60 consecutive days. You may incur multiple Part A deductibles if you have more than one benefit period within a year.

For Medicare Part B, there is an annual deductible. In 2025, this deductible is $257. Once this annual deductible is met, you pay a portion of the Medicare-approved amount for most Part B services.

Coinsurance represents a percentage of the cost of a Medicare-approved service that you are responsible for paying after your deductible has been met. For Part B services, the coinsurance is 20% of the Medicare-approved amount. For example, if a service’s Medicare-approved amount is $100, you would pay $20.

For Part A inpatient hospital stays, there is no coinsurance for the first 60 days in a benefit period. From day 61 to day 90, the coinsurance is $419 per day in 2025. If your hospital stay extends beyond 90 days, you use “lifetime reserve days,” which have a daily coinsurance of $838 per day in 2025. For skilled nursing facility stays, there is no coinsurance for the first 20 days, but it is $209.50 per day for days 21 through 100 in 2025.

Copayments are fixed dollar amounts you pay for certain services, seen more often with Medicare Advantage plans or for specific Part B services like doctor visits or therapy sessions.

Original Medicare (Parts A and B) does not have an annual out-of-pocket maximum. Without supplemental coverage, your financial responsibility for coinsurance and deductibles could be unlimited. Many beneficiaries choose supplemental coverage, such as Medigap policies or employer-sponsored retiree health plans, to help cover these costs. These plans can significantly reduce your financial exposure by paying for deductibles, coinsurance, and copayments that Original Medicare does not cover.

Factors Influencing Total Cost

The total cost of a knee replacement, and your out-of-pocket share, can vary based on several influencing factors. These variables impact the overall expense of the procedure and subsequent recovery. Understanding these elements helps explain why costs are not uniform across all cases.

One significant factor is the type of facility where the surgery is performed. Costs can differ between large inpatient hospitals, smaller outpatient surgery centers, or specialized orthopedic hospitals. Outpatient procedures cost less than inpatient ones due to shorter facility stays. The choice of facility also depends on the case’s complexity and the patient’s overall health.

Geographic location also plays a role in determining costs. The average cost of a knee replacement can vary depending on the state, city, or region within the United States. For instance, total knee replacement costs in the U.S. can range from $15,000 to $75,000, with some analyses showing averages around $20,000 to $29,300 for uncomplicated cases, but potentially much higher.

The complexity of the procedure and the patient’s health status are also determinants. Pre-existing medical conditions, complications during or after surgery, or the need for more extensive post-operative care can lead to increased overall costs. For example, a partial knee replacement costs less than a total knee replacement because it is a less invasive procedure. Revision surgeries, which address issues with previous replacements, are the most expensive.

The specific type of implant used in the surgery can also affect the total cost. While Medicare covers medically necessary implants, there can be variations in cost based on the prosthetic design and materials chosen by the surgeon and hospital. Implant costs alone can range from $3,000 to $10,000.

Beyond the surgery itself, post-operative care is a component of the total cost. This includes expenses for rehabilitation, physical therapy sessions, and follow-up appointments. The intensity and duration of these recovery services can vary among patients, directly impacting the overall expenditure.

Steps to Estimate Your Specific Costs

Estimating your specific out-of-pocket costs for a knee replacement requires engagement with your healthcare providers and Medicare plan. These steps allow you to gather personalized financial information before your procedure. The goal is to obtain a clearer picture of your potential financial responsibility.

Begin by consulting your healthcare provider, including your surgeon’s office and the hospital or facility where your surgery will take place. Request an estimated cost breakdown that includes facility fees, surgeon’s fees, anesthesia charges, and anticipated post-operative care.

Next, contact your specific Medicare plan directly. If you have Original Medicare, you can call 1-800-MEDICARE to inquire about general coverage details and cost-sharing for knee replacement procedures. If you are enrolled in a Medicare Advantage plan or have a Medigap policy, contact your plan provider to understand your specific cost-sharing, including any remaining deductibles, coinsurance rates, and pre-authorization requirements. Confirming these details with your plan ensures you are aware of your financial obligations.

After services are rendered, you will receive a Medicare Summary Notice (MSN) if you have Original Medicare, or an Explanation of Benefits (EOB) from your Medicare Advantage plan. These documents are not bills but provide a summary of services billed to Medicare, what Medicare paid, and the maximum amount you may owe. While these documents detail past costs, they are valuable for verifying accuracy and understanding how your benefits were applied. Comparing these notices with your own records can help identify any discrepancies.

Many hospitals have financial counselors who can help you navigate potential costs and discuss payment options or financial assistance programs. These resources can provide support in understanding and managing the expenses associated with your knee replacement surgery.