How Much Will Medicare Pay for Total Knee Replacement?

A total knee replacement is a common orthopedic surgery that involves replacing damaged bone and cartilage in the knee joint with artificial components. This procedure can significantly improve mobility and alleviate pain for individuals with severe knee damage, often due to arthritis. Many people considering this surgery wonder how Medicare covers the costs. This article clarifies how Medicare helps pay for a total knee replacement, detailing the financial responsibilities involved and explaining how different Medicare options can influence your out-of-pocket expenses.

Medicare Part A Coverage for Total Knee Replacement

Medicare Part A, also known as Hospital Insurance, primarily covers inpatient hospital stays and related services. For a total knee replacement, Part A covers the facility costs associated with your inpatient hospitalization. This covers your room, meals, general nursing care, and other services during your hospital stay.

Beneficiaries are responsible for a deductible for each benefit period. In 2025, the Part A inpatient hospital deductible is $1,676. A benefit period begins the day you are admitted as an inpatient and ends when you have not received inpatient hospital care for 60 consecutive days. There is no limit to the number of benefit periods you can have in a year, meaning you might pay this deductible more than once if you have separate inpatient stays that start new benefit periods.

If your hospital stay extends beyond 60 days within a benefit period, co-insurance amounts apply. For days 61 through 90, the daily co-insurance is $419 in 2025. If the inpatient stay continues past 90 days, you would use your lifetime reserve days, for which the daily co-insurance is $838 in 2025. Each beneficiary has 60 lifetime reserve days that can be used once.

Part A also covers a stay in a skilled nursing facility (SNF) if it is medically necessary after an inpatient hospital stay, such as for rehabilitation following a knee replacement. Medicare covers 100% of the cost for the first 20 days in a SNF. For days 21 through 100, a daily co-insurance applies, which is $209.50 in 2025. After day 100 in a SNF within a benefit period, you are responsible for all costs.

Medicare Part B Coverage for Total Knee Replacement

Medicare Part B, or Medical Insurance, covers professional services and outpatient care related to a total knee replacement. This includes the fees for the surgeon and other doctors involved in your care, such as pre-operative consultations and post-operative follow-up visits. Part B also covers outpatient physical therapy, which is often a significant component of recovery after knee surgery.

Beyond surgical and physician services, Part B covers durable medical equipment (DME) that your doctor prescribes, such as crutches, walkers, or wheelchairs, which are often necessary during the recovery phase. Certain outpatient rehabilitation services are also covered under Part B.

For most Part B-covered services, you are responsible for an annual deductible. In 2025, the annual Part B deductible is $257. After this deductible is met, Medicare generally pays 80% of the Medicare-approved amount for services, and you are responsible for the remaining 20% co-insurance. This 20% co-insurance applies to doctor fees, outpatient therapy, and DME after your deductible is satisfied. Unlike Part A, Part B does not have benefit periods; its deductible is an annual amount.

Understanding Your Out-of-Pocket Costs

It is important to remember that Medicare only covers services deemed medically necessary. Your doctor must determine that a total knee replacement is appropriate for your condition, and in some cases, pre-authorization from Medicare or your healthcare provider might be required. The actual costs can vary considerably based on the complexity of your procedure, the length of your hospital stay, the extent of rehabilitation needed, and the specific Medicare-approved amounts for services in your area. Discussing potential costs with your healthcare provider and the hospital’s billing department before the procedure can help you anticipate your financial responsibility.

How Medicare Advantage and Medigap Affect Costs

Medicare Advantage plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover everything Original Medicare (Parts A and B) covers, but they may have different cost-sharing structures, such as co-payments for services instead of the 20% co-insurance found in Original Medicare. Medicare Advantage plans often include an annual out-of-pocket maximum, which limits how much you will pay for covered services in a year. For 2025, the maximum out-of-pocket limit for in-network costs in Medicare Advantage plans is $9,350.

These plans often bundle additional benefits not covered by Original Medicare, such as prescription drug coverage, vision, or dental care. While you generally pay your Part B premium, many Medicare Advantage plans have low or no additional monthly premiums. Your out-of-pocket costs for a total knee replacement under a Medicare Advantage plan would depend on the specific plan’s co-pays, deductibles, and co-insurance for hospital stays, doctor visits, and rehabilitation.

Medigap policies, also known as Medicare Supplement Insurance, are different from Medicare Advantage plans. Medigap policies work alongside Original Medicare to help pay for some of the out-of-pocket costs that Original Medicare does not cover. These policies can help cover deductibles, co-payments, and co-insurance amounts from Part A and Part B. For example, a Medigap plan could cover the Part A hospital deductible, the Part B deductible, and the 20% Part B co-insurance, significantly reducing your financial burden for a total knee replacement.

Since Medigap policies supplement Original Medicare, you must remain enrolled in both Part A and Part B. The specific benefits and premiums of Medigap policies vary by plan type and the insurance company offering them. Choosing a Medigap plan can provide more predictable out-of-pocket expenses by covering a larger portion of the costs associated with a complex procedure like a total knee replacement.