How Much Does Medicare Pay for Knee Replacement?

Medicare, a federal health insurance program, helps millions of Americans, primarily those aged 65 or older and individuals with certain disabilities, manage their healthcare expenses. Knee replacement surgery is a common procedure covered by Medicare. Understanding how Medicare contributes to the cost of this surgery is important for beneficiaries, as out-of-pocket expenses can vary significantly based on the type of Medicare coverage. This article details the financial aspects of knee replacement under different Medicare plans, highlighting patient responsibilities.

Original Medicare Coverage and Costs for Knee Replacement

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Part A primarily covers inpatient hospital care, including the surgery, hospital room, nursing services, and supplies during a qualifying inpatient stay. For 2025, beneficiaries are responsible for a Part A deductible of $1,676 per benefit period. A benefit period begins when a person is admitted as an inpatient to a hospital or skilled nursing facility and ends after 60 consecutive days of not receiving inpatient care.

If an inpatient hospital stay extends beyond 60 days within a benefit period, coinsurance amounts apply. From days 61 through 90, the daily coinsurance is $419. Should the stay continue past 90 days, beneficiaries use their lifetime reserve days, incurring a daily coinsurance of $838 for up to 60 additional days over their lifetime.

Medicare Part B covers medical services outside of inpatient hospital care, including surgeon’s fees, anesthesiologist services, and other physician services related to the surgery. Outpatient services, such as doctor visits before and after the surgery, are also covered. For 2025, the annual Part B deductible is $257. After this deductible is met, Medicare Part B covers 80% of the Medicare-approved amount for most services, leaving the beneficiary responsible for the remaining 20% coinsurance.

Medicare Advantage Plans and Knee Replacement Costs

Medicare Advantage plans, also known as Part C, are offered by private insurance companies approved by Medicare and provide an alternative way to receive Original Medicare benefits. These plans are required to cover at least all the services that Original Medicare (Parts A and B) covers. Many Medicare Advantage plans also include additional benefits, such as prescription drug coverage, vision, or dental care.

The cost structure of Medicare Advantage plans differs from Original Medicare, often featuring copayments for services rather than the deductibles and coinsurance of Parts A and B. For instance, a Medicare Advantage plan might charge a fixed copayment for doctor visits instead of a 20% coinsurance. Specific copayment amounts for hospital stays, doctor visits, and other services vary significantly between plans and geographic locations.

A significant feature of Medicare Advantage plans is the annual out-of-pocket maximum, which caps a beneficiary’s spending for covered Part A and Part B services in a calendar year. For 2025, the out-of-pocket limit for in-network services under Medicare Advantage plans is $9,350, though individual plans can set lower limits. Once this maximum is reached, the plan pays 100% of covered services for the remainder of the year. Many Medicare Advantage plans operate with provider networks, and using out-of-network providers can result in higher out-of-pocket costs.

Related Services and Factors Affecting Your Total Costs

Knee replacement recovery often involves several related services that contribute to the total cost. Skilled Nursing Facility (SNF) care may be necessary for post-hospital rehabilitation. Medicare Part A covers SNF care for a limited time following a qualifying hospital stay. For 2025, Medicare covers the full cost for the first 20 days of SNF care, but a daily coinsurance of $209.50 applies for days 21 through 100. After day 100, the beneficiary is responsible for all costs.

Outpatient physical and occupational therapy are crucial components of rehabilitation after knee replacement. Medicare Part B covers these services, with beneficiaries paying a 20% coinsurance of the Medicare-approved amount after meeting the annual Part B deductible. Durable Medical Equipment (DME), such as walkers or crutches, is also covered under Part B, with the same 20% coinsurance applying.

Prescription medications are often needed post-surgery. For Original Medicare beneficiaries, these drugs are covered under a separate Medicare Part D prescription drug plan, which involves varying premiums, deductibles, and copayments. Starting in 2025, annual out-of-pocket costs for covered Part D drugs are capped at $2,000. Medicare Advantage plans often include prescription drug coverage.

Several factors influence the total out-of-pocket costs for a knee replacement. Coverage is contingent on the procedure being medically necessary, and prior authorization may be required. The choice of provider and facility can also affect expenses. Geographic location plays a role, as healthcare costs differ across regions. For Original Medicare beneficiaries, supplemental insurance policies, known as Medigap, can help cover deductibles, coinsurance, and copayments.