A knee replacement, also known as an arthroplasty or total knee replacement, is a surgical procedure that helps reduce pain, improve mobility, and more for those with knee issues that have not seen relief through other methods.
Original Medicare covers most of the costs of total knee replacements if it is deemed as a medical necessity. Costs will depend on whether the procedure is an inpatient surgery or performed in an outpatient setting.
Medicare Advantage plans also will cover most of the costs of a knee replacement procedure.
Medicare supplement insurance plans may also help drive knee surgery costs lower.
In the event a Medicare beneficiary needs knee replacement surgery, they may be wondering about how Medicare coverage works with this type of procedure. In short, Medicare covers some of the costs associated with knee replacement surgery, so long as the patient’s doctor declares the procedure to be medically necessary.
One’s exact Medicare plan, be it an Original Medicare plan, a Medicare Advantage plan, or otherwise will dictate the patient’s financial obligations further. This resource will explain everything that needs to be understood about Medicare and knee replacement surgery.
What Is A Knee Replacement?
A knee replacement, also known as an arthroplasty or total knee replacement, is a procedure in which a surgeon replaces the knee joint.
Benefits of getting a knee replacement include:
Reduces knee pain
Note: Learn more about knee replacement surgery at this resource.
How Much Does a Knee Replacement Cost?
The total cost of a knee replacement is extremely expensive, averaging around $50,000 without insurance.
Overall, knee replacement surgery costs will vary based on a variety of factors. Some of these may include:
Whether it is an outpatient knee replacement surgery or inpatient
What type of facility performs the procedure
Prescription medications that may be needed for pain relief, to prevent blood clots, etc.
Anesthesia type and amount
Inpatient hospital stay (if applicable)
Does Medicare Cover Knee Replacement Surgery?
Most knee replacement costs are covered by Medicare. That said, the knee replacement must be deemed medically necessary by a healthcare professional in order for Medicare to cover the procedure. Also, a patient should still count on there being out-of-pocket expenses.
Average Medicare Costs
On average, Medicare will cover $8,063 of a procedure performed at ambulatory surgical centers, meaning Medicare beneficiaries are left to cover around $2,015 on average.
For knee replacement surgeries done at a hospital outpatient department, Medicare will cover $11,886, leaving Medicare beneficiaries to cover the remaining 20 percent or $1,748 on average.
Knee replacements have costs beyond the procedure itself. Prescription medications, walkers, knee braces, physical therapy, follow-up doctor visits, and more. These will be covered under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).
Note: Learn more about knee replacement surgery and Medicare costs at this resource.
Medicare Part A
Medicare Part A is Medicare’s hospital insurance. Medicare Part A covers inpatient services after beneficiaries have met their Part A deductible. Most patients do have knee replacement surgeries within an inpatient setting and stay in the hospital for a few days after the procedure.
Medicare Part B
Medicare Part B is Medicare’s medical insurance. Medicare Part B covers outpatient services. In 2018, Medicare began to allow coverage for knee replacement surgeries performed outpatient, meaning without staying in the hospital overnight. Medicare Part B will cover up to 80% of allowable charges for a knee replacement so long as the beneficiary has met their yearly deductible. In 2022, the deductible is $217.
Part B will also cover 80% of allowable charges for what’s medically necessary after the surgery such as, physical therapy, occupational therapy, and/or durable medical equipment like a walker or cane.
Note: Learn more about Medicare coverage in 2022 at this resource.
Medicare Part D
Medicare Part D is Medicare’s prescription drug coverage. Following knee replacement surgery, prescription drugs may be necessary to reduce pain, prevent blood clots, etc. While prescription drug plans will vary in what’s covered, Medicare beneficiaries can confirm what drugs are covered on the plan’s formulary.
Do Medicare Advantage Plans Cover Knee Replacement Surgery?
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 knee replacement surgeries are covered.
That said, Medicare Advantage plans may provide additional benefits in addition to standard Original Medicare coverage. This may include prescription drug coverage and help with premium payments. These benefits may help lower a patient’s overall out-of-pocket costs associated with a knee replacement.
Are There Other Medicare Benefits to Help Pay for Knee Replacements?
There are other components of the federal Medicare program that can help out-of-pocket costs. These include Medicare supplement insurance plans.
Medicare Supplement Insurance Plans
Medicare supplement insurance plans, also known as MedSupp or Medigap, are supplemental insurance policies that “fill in the gaps” of Original Medicare.
A Medicare supplement plan is in addition to Original Medicare, beneficiaries should still expect their Medicare plan to still cover around 80 percent of knee surgery costs, with their financial responsibility being 20 percent, unless they’ve already met their yearly deductible.
Similar to MA plans, Medigap policies may reduce out-of-pocket costs. However, cost coverage is all dependent on the specific plan and insurance company.