What to Know About Medicare and Hip Replacement Surgery

• A hip replacement is a procedure that removes diseased or damaged parts of the hip joint and replaces them with new, artificial parts. The surgery can help relieve pain, enhance mobility, and improve hip joint functionality.

• A hip replacement must be deemed medically necessary for Medicare to provide coverage. If this is true, Medicare will usually cover around 80 percent of the associated costs, leaving beneficiaries responsible for the remaining 20 percent.

• Medicare Advantage plans or Medigap plans may help drive prices lower. This will be dependent on each individual medicare supplement plan, however.

A hip replacement, also known as an arthroplasty, is a procedure in which a surgeon will remove the diseased parts of a hip joint and replace them with new, artificial pieces that duplicate normal hip functioning. Replacement parts may be made with metal, plastic, ceramic, or a combination of these materials.

When Would You Need a Hip Replacement?

A person may need a hip replacement due to certain conditions that wear down the hip joints, including osteoporosis, hip injury, or rheumatoid arthritis, among others.

When the hip joints wear down, a person can experience pain, a loss of joint function, and limited mobility.

Hip Replacement Benefits

Benefits of getting a hip replacement include:

• Relieves hip pain

• Enhances mobility

• Improves hip joint functionality

Original Medicare usually covers around 80 percent of the surgery costs associated with hip replacement surgery, so long as the procedure is considered medically necessary. The patient is then financially responsible for the remaining 20 percent.

These costs, referred to as the Medicare-approved amount, will vary based on procedure location i.e. whether it is performed at an outpatient surgical facility or at an inpatient facility. Different parts of Medicare will cover certain aspects.

Medicare Part A

Medicare Part A is Original Medicare’s hospital insurance. It covers inpatient treatment and some related hospital stay costs at a Medicare-approved hospital when getting hip replacement surgery, such as:

• Semi-private hospital room

• Drugs administered during hospital stay

• Meals

• Nursing care

Medicare Part B

Medicare Part B covers outpatient procedures and care. If the surgery is performed at an outpatient facility, Part B will help cover the cost. Additionally, Part B contributes to other outpatient preparations and procedures that must occur before surgery, such as:

• Physical examination

• Full hip examination

• an MRI

• Post-operative physical therapy

• Radiography

Medicare Part D

Part D is a plan offered by private insurance companies that cover prescription medications, which are important for pain management after the surgery. Some medications a person may need after surgery include:

• Pain relief medications, NSAIDs (non-steroidal anti-inflammatory drugs)

• Blood thinners

• Antibiotics

Hip Replacement Costs

Below are the procedure costs for a total hip replacement surgery and what Medicare pays.

Average Ambulatory Hip Replacement Costs

• Total Cost:$10,808

• Medicare Covers: $8,646

• Patient Covers: $2,161

Average Outpatient Hip Replacement Costs:

• Total Cost: $14,348

• Medicare Covers: $12,488

• Patient Covers: $1,860

Other Associated Hip Replacement Surgery Costs

In addition to the actual procedure, hip replacements also include other medical expenses. Some such expenses may include:

A walker

Medicare Part B, medical insurance, covers this as durable medical equipment.

Outpatient physical therapy

Some patients may require outpatient physical therapy following their knee replacement. Physical therapy is covered under Medicare Part B. Learn more about Medicare and coverage for physical therapy at this resource.

Prescription drugs coverage

Medicare Part D covers prescription drugs, so anything needed as part of a pain management plan would fall under this Medicare Part.

Follow-up medical visits

Follow-up visits may be necessary for some patients. Costs will vary.

Skilled nursing care

Skilled nursing care may be necessary for some patients. Skilled nursing care is covered if a beneficiary has Medicare Part A as well as days remaining in their benefit period they can use for the stay. As well, it would need to be a qualifying hospital stay. Learn more at this resource.

Medicare Advantage (MA) plans are health plans offered by private insurance companies that are Medicare-approved. MA plans, also known as Medicare Part C, bundle Medicare Part A and Medicare Part B coverage. As such, MA plans have the same covered services as Original Medicare, meaning hip replacement surgeries are covered.

That said, Medicare Advantage plans may provide additional benefits to those provided by standard Original Medicare. Added benefits may include prescription drug coverage and assistance with premium payments. These benefits may help lower the overall out-of-pocket costs associated with a hip replacement. These will vary depending on a patient’s individual plan, however. As such, Medicare beneficiaries should consult their insurance company to understand their exact costs.

MedSupp/​Medigap, are Medicare supplement plans that ​“fill in the gaps” of Original Medicare. These plans are in addition to Original Medicare. As such, Medicare beneficiaries should expect their Medicare plan to still cover 80 percent of hip replacement costs, with their financial responsibility being 20 percent.

As well, Medigap policies may reduce out-of-pocket costs depending on the specific plan and the insurance company.

Does Medicare cover all costs of hip surgery?

Original Medicare does cover 80% of certain hip surgery costs, provided the procedure is deemed medically necessary.

What makes hip surgery medically necessary?

If the hip pain causes extreme pain that isn't alleviated by medications and interferes with day-to-day tasks such as work and sleep, then a hip replacement surgery is likely to be deemed medically necessary.