Shoulder replacement surgery came about in the late 1950’s in the United States. Since then, there has been well over 52,000 people who have undergone shoulder replacement surgery each year. As ailing Medicare beneficiaries consider or follow through with a shoulder replacement it is crucial to understand the coverage and options available. Luckily, Medicare offers a portion of coverage for shoulder replacement surgery if deemed medically necessary.
What Determines if Shoulder Replacement Surgery is Elective or Medically Necessary?
Shoulder injuries or shoulder problems caused by an illness like arthritis can restrict your shoulder range of motion (ROM). You may have pain when you try to move your arm and shoulder, and this restricts your overall activity.
You become more sedentary, and exercise less than you did without the pain. This leads to a chain reaction-like response where, since you have pain and are less likely to move, you develop circulation problems causing you to have higher blood pressure, cardiovascular issues, and even weight gain.
Your physician will need to certify to Medicare that shoulder replacement surgery is medically necessary in order for your shoulder to heal and to prevent further damage to your overall health. Your surgeon must be a Medicare-approved physician who participates in Medicare.
What Will My Cost for Shoulder Replacement Surgery be After Medicare Pays its Part?
It is almost impossible to know what your exact costs will be prior to having the procedure. But your physician should be able to tell you what services to expect so you can estimate your costs. Questions to ask your physician include:
- Will you need to be admitted to the hospital for the procedure and stay overnight?
- Can the procedure be done on an outpatient basis? If so, can you choose between an ambulatory surgical center or the hospital outpatient department?
Medicare Part A Coverage if Your Procedure is Done as a Hospital Inpatient
If your shoulder replacement is determined to be medically necessary and is performed in a hospital where you are an inpatient, Medicare Part A will pay a portion of the covered costs for your stay in the hospital, for the procedure itself, and for a medically necessary stay in a skilled nursing facility for rehabilitation if required.
There are limits to your benefits. Under Original Medicare Part A you may pay:
- A $1,408 deductible. This covers the first 60 days of hospitalization or medically necessary stay in a skilled nursing facility.
- On day 61, if you are still hospitalized, you will pay a coinsurance cost of $352 a day for days 61 to 90 in any benefit period.
- If you are in a skilled nursing facility from days 21 through 100 in any benefit period, your coinsurance is $176 a day.
These are estimates and your out-of-pocket expenses may vary depending on your geographical location and other factors. Ask your doctor’s office to give you a written estimate with a range of potential costs.
Medicare Part B Coverage if Your Procedure is Performed in an Outpatient Facility
If your shoulder replacement is performed in an outpatient facility, under Original Medicare Part B you will pay:
- Your annual Part B deductible of $198.
- Your monthly premium, which for most beneficiaries is $144.60.
- Your coinsurance which is 20% of the Medicare-approved cost.
- If you need physical therapy or any durable medical equipment, you will pay 20% of those costs.
Costs if You have a Medicare Advantage Plan
You will need to review your specific plan. Plans vary and do not all provide you with the same coverage. You can call your insurance carrier and get accurate information about the specific coverage and learn exactly what the amount of your copay will be.
Your Medicare Advantage Plan, according to the law, must provide you with at least the amount of coverage provided by Original Medicare for both inpatient and outpatient services. Generally, Advantage Plans provide you with greater coverage. It may also cover prescription drugs.
Costs if You Have a Medicare Supplemental Insurance
As with an Advantage Plan, you must check your specific Medigap plan to see how much it will pay of your out-of-pocket costs. It may cover some of the following:
- Your copays
- Legally, it cannot cover your Part B premium.
- Check to see if you have Part D coverage with your Medigap plan for your prescription drugs.
Medicare Procedure Price Lookup Tool
Medicare has a “procedure price lookup tool” that allows you to enter the procedure name or code, and it will provide you with detailed information about what costs you can expect. It is important to get the name and code number from your physician since there are different code numbers depending on the exact type of shoulder replacement surgery the surgeon has determined you need.
- Procedure Price Lookup Tool, Medicare.
- Surgery Coverage and Costs, Medicare.