Medicare will cover specific expenses of Knee Replacement surgery if it is considered medically necessary by a doctor.
Medicare Part A and Part B coverage is subject to change based on if the beneficiary is considered inpatient or outpatient.
Medigap may also help with some out-of-pocket expenses you experience.
Knee replacement surgery is extremely successful at providing symptom relief for individuals who have not seen improvements with non-surgical treatments, such as physical therapy and injections. Medicare does provide some coverage for knee replacement surgery and it is one of the most common surgeries for Medicare beneficiaries. In fact, 754,000 knee placement surgeries were performed before the pandemic.
When Does Medicare Provide Coverage for Knee Replacement Surgery?
Not all knee replacement surgeries may be covered by Medicare. For Medicare to cover some of the expenses of knee replacement surgery, the procedure must be deemed reasonable and medically necessary.
A procedure is considered reasonable and medically necessary when it meets the following criteria:
- Used to diagnose or treat an illness, medical condition or injury and any associated symptoms
- Procedure must meet medical standards
- Be ordered and performed by a qualified medical professional
- Procedure must be performed in a setting that is deemed appropriate for the procedure and the unique medical needs of the patient
- Other non-surgical treatment options may have been tried but have proven unsuccessful
What Expenses Does Medicare Cover for Knee Replacement Surgery?
How much Medicare covers and what exactly it pays for varies depending upon your unique situation. Some of the expenses that Medicare may cover include:
- Preoperative testing and exams
- Cost of the procedure and use of surgical center
- Cost of the surgeon and medical support staff
- Physical therapy
- Hospital stays
- Nursing care
- Skilled nursing care
- Durable medical equipment
- Post-operative doctors’ appointments and follow-up appointments
A primary determining factor in beneficiary coverage and cost is whether the procedure was performed as an inpatient or outpatient.
What Does Medicare Part A Cover for Knee Replacement Surgery?
Medicare Part A is commonly referred to as “hospital insurance”. because it provides coverage for medical care that has been administered in a Medicare-approved hospital. For more information visit Original Medicare Coverage (Parts A & B).
Medicare Part A provides coverage for the following expenses:
- Semi-private hospital room with a private bathroom
- Medical care administered in the hospital – such as anesthesia, physical therapy, and the surgical procedure
- Nursing care
Payment of a deductible is required before Medicare Part A provides coverage. In 2022, the deductible for Medicare Part A was $1,556 per benefit period. A benefit period is defined as starting on the first day a beneficiary is admitted to the hospital or other inpatient facility, and it ends when the beneficiary has not received any care in a hospital or skilled nursing facility for 60 consecutive days.
A co-pay may be needed after you have paid your Medicare Part A deductible. However, it will vary depending upon what procedure is performed and how long you are receiving care.
Does Medicare Cover Inpatient Physical Therapy After Knee Replacement Surgery?
Inpatient physical therapy, which is usually administered at a skilled nursing facility, may be covered by Medicare. Your doctor or surgeon will need to determine that the extra care is necessary and needed. You must also be getting care at a Medicare-approved skilled nursing facility.
Medicare Part A would provide coverage for your stay at the skilled nursing facility. Medicare Part A will cover some or all of the cost of medical care, physical therapy, meals, medications, medical equipment, and your stay in the facility for up to 100 days.
What Does Medicare Part B Cover for Knee Replacement Surgery?
Medicare beneficiaries needing knee replacement surgery will receive coverage under Medicare Part B for two reasons: preoperative testing and outpatient procedures/care.
Whether your procedure will be performed inpatient or outpatient, Medicare Part B provides coverage for any preoperative testing or examinations that need to be performed before your knee replacement surgery. Any physicals, exams, blood tests and imaging that is performed as an outpatient, meaning not as part of the hospital stay for your procedure, will be covered by Medicare Part B.
Medicare Part B is also responsible for covering some of the expenses you experience if your knee replacement surgery is performed as an outpatient procedure. Some of the expenses that will be covered by Medicare Part B include:
- Surgeon and medical support staff such as nurses and anesthesiologist
- Medical testing
- Physical therapy
- Postoperative appointments
- Use of the Medicare-approved outpatient facility or surgical center
- Expenses related to the procedure
- Durable medical equipment, such as walkers and canes
Medicare Part B does not provide coverage for medications or prescriptions that are given for knee replacement surgery. Medicare Part D, a separate coverage that is often provided by private insurance companies, will provide coverage for medications and prescriptions that are needed when you are at home.
How Much Do You Need to Pay Before Medicare Part B Covers Knee Replacement Surgery?
Before Medicare Part B will provide coverage for any expenses related to your knee replacement surgery, you must pay a monthly premium and then meet a deductible. Once you pay the premium and deductible, Medicare will cover a portion of your expenses, usually 80%, and you will be responsible for the remaining 20%.
The monthly premium that you pay for Medicare Part B varies depending upon your income. However, the standard Medicare Part B premium for 2022 was $170.10. Those that earned more paid more than the standard rate.
The deductible for Medicare Part B in 2022 was $233. For more information visit Original Medicare Costs (Parts A & B).
How Does Medigap Help with Costs of Knee Replacement Surgery?
Medigap, or Medicare Supplement Plans, can help you pay out-of-pocket expenses you experience as part of your knee replacement surgery. With Medigap plans, you will need to pay an additional monthly premium to a private insurance company.
A Medigap plan can help you pay for the remaining 20% of the expenses that aren’t covered by Medicare Part B. The amount that is covered will vary depending upon your plan. Medigap can also help pay for Medicare Part B premiums, deductibles, and any copays.