Is Knee Replacement Surgery Covered by Medicare?

Knee replacement surgery offers relief for individuals with severe knee pain and functional limitations. Also known as knee arthroplasty, this procedure can improve mobility and quality of life when other treatments have failed. Medicare often covers knee replacement surgery, allowing many to access this intervention.

Original Medicare Coverage for Knee Replacement

Original Medicare, comprising Part A (Hospital Insurance) and Part B (Medical Insurance), covers knee replacement surgery when medically necessary. Part A covers inpatient hospital stays, including the surgery, hospital services, and skilled nursing facility (SNF) care after discharge. If the knee replacement is an inpatient procedure requiring an overnight stay, Part A covers these costs.

Medicare Part B covers medical services typically provided on an outpatient basis. This includes doctor services from surgeons and anesthesiologists, outpatient therapy like physical and occupational therapy, and durable medical equipment (DME) such as walkers or crutches. If the knee replacement is an outpatient procedure, Part B covers the surgery, doctor visits, and subsequent rehabilitation.

Medical necessity is required for coverage under both Part A and Part B. A doctor must determine the surgery is appropriate based on criteria like severe pain or functional limitations impacting daily activities. The doctor must also document that other conservative treatments, such as medications or physical therapy, have been unsuccessful.

Understanding Your Out-of-Pocket Costs

While Original Medicare covers a portion of knee replacement surgery, patients are responsible for certain out-of-pocket costs. These include deductibles, coinsurance, and copayments, which vary by care setting. For Part A services, a deductible applies for each benefit period. A benefit period begins when you are admitted as an inpatient to a hospital or skilled nursing facility and ends after you have been out of the facility for 60 consecutive days.

Part A also involves coinsurance for extended hospital stays or skilled nursing facility care. For inpatient hospital stays, there is no coinsurance for the first 60 days in a benefit period, but a daily coinsurance applies for days 61 through 90. For skilled nursing facility care, there is no coinsurance for the first 20 days, followed by a daily coinsurance for days 21 through 100.

Medicare Part B has an annual deductible. Once met, patients pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment. Medicare pays the remaining 80%.

Preparing for Coverage

Before knee replacement surgery, proactive steps can help ensure Medicare coverage. Thorough documentation of medical necessity by your doctor is important. This documentation should detail the severity of your knee condition, how it limits daily activities, and specific conservative treatments attempted unsuccessfully. Medicare requires evidence that non-surgical interventions, often for several months, have been tried and failed.

Selecting healthcare providers and facilities that accept Medicare assignment is important. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment, limiting your out-of-pocket costs to the deductible and coinsurance. You can confirm a provider’s participation by asking them or using Medicare’s online Care Compare tool. Choosing a provider who does not accept assignment could result in higher costs, including “excess charges.”

While Original Medicare does not require pre-authorization for the surgery itself, it might be necessary for certain related services. This includes specific durable medical equipment or extended skilled nursing facility stays. Patients should confirm any pre-authorization requirements with their doctor’s office and the facility to avoid unexpected costs.

Medicare Advantage and Supplemental Plans

Beyond Original Medicare, beneficiaries have additional options: Medicare Advantage (Part C) plans and Medicare Supplement Insurance (Medigap) policies. Medicare Advantage plans are offered by private insurance companies and must cover at least the same services as Original Medicare Parts A and B. These plans may have different rules for accessing care, such as network restrictions, referral requirements, and often mandate pre-authorization for services like knee replacement surgery.

Medicare Advantage plans have an annual out-of-pocket maximum, capping the total amount a beneficiary might pay for covered services in a year. This provides financial predictability, unlike Original Medicare which has no such limit. Individuals with a Medicare Advantage plan should contact their plan provider to understand their cost-sharing structure, including deductibles, copayments, and coinsurance for a knee replacement.

Medigap policies work differently; they cover some of the out-of-pocket costs associated with Original Medicare. These policies help pay for expenses like deductibles, coinsurance, and copayments that Original Medicare does not fully cover. Medigap plans work with Original Medicare, not as a replacement, and can reduce the financial burden of a knee replacement for those with Original Medicare.