Does Medicare Cover Knee Replacements?Find out what coverage Medicare offers for knee replacement surgery and related treatments.
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Knee replacements are one of the most common surgeries for older people in the U.S. According to the American Joint Replacement Registry, there were around 2.4 million knee and hip replacement surgeries in 2021 alone.
If you’ve recently joined Medicare or recently found out you need a knee replacement as a Medicare beneficiary, you’re probably wondering what it will cost and whether Medicare will help pay for the procedure.
Read our guide to find out exactly what Medicare will cover when it comes to knee replacement surgery and how much you’ll have to pay if you decide to get it done.
Does Medicare Cover Knee Replacement surgery?
If your knee replacement surgery is deemed to be medically necessary, then Medicare will cover the cost of the procedure at Medicare-approved rates.
However, if the procedure isn’t determined to be medically necessary, you will have to cover the cost of the procedure out-of-pocket.
It’s important to remember that there are different parts to the federal Medicare program that will cover you for different types of expenses. The amount of coverage you’ll get and the amount you’ll need to spend will depend on the type of surgery and how it’s classified by Medicare.
What If My Doctor Doesn’t Charge Medicare-Approved Rates?
If your surgeon or physician charges more than the Medicare-approved amount, they will cover your treatment up to their approved amount and you will be liable for the difference.
However, if your doctor accepts Medicare assignment (which means they are willing to treat a Medicare beneficiary), then they are limited to charging a maximum of 15% more than what Medicare will cover.
You can either have a knee replacement procedure as an outpatient or inpatient depending on the severity of your knee issue and the amount of surgical work required to replace or repair the damage.
Ask Your Doctor If Your Treatment Will Be Outpatient or Inpatient
Depending on where and how you’re treated, your knee replacement surgery will be covered by different parts of Medicare. This is particularly important because each part of Medicare has different coinsurance amounts and deductibles, which Medicare beneficiaries have to cover.
Medicare Part A is coverage for hospital or inpatient medical treatment.
Medicare Part B is coverage for general or outpatient medical treatment, such as durable medical equipment, tests, screenings, or doctors visits.
Let’s take a look at a couple of scenarios to help you understand how much Medicare will cover your knee replacement.
If you have outpatient knee replacement surgery scheduled, you’ll be covered under Medicare Part B. This is Medicare coverage for nonhospital costs and general medical expenses.
If your doctor charges the Medicare-approved rate, your Medicare Part B coverage will pay 80% of the costs of your outpatient surgery and you will be required to pay 20% of the costs as a coinsurance amount.
What Is Coinsurance?
Coinsurance is a portion of the costs of treatment that the Medicare beneficiary needs to cover. This is different to the deductible, which is the amount of money you will need to pay before your coverage kicks in.
For example, let’s say your knee replacement surgery costs $4,500 and your doctor accepts Medicare assignment. Your Medicare cover will pay $3,600 of the expenses and you will need to pay: Coinsurance: $900 Deductible: $233 Monthly Premium: $170.10 Total Costs To You: $1,270.10
When Is It Inpatient and When Is It Outpatient?
You are an inpatient as soon as you are officially admitted to a hospital and placed under their care. You are an outpatient if you are not admitted to the hospital.
In some cases, you may have surgery in a hospital, but you are still considered to be an outpatient.
It’s important to check with your physician or the attending medical staff to find out what your status is as it has cost implications for your Medicare coverage.
Inpatient surgery is covered under Medicare Part A and works on a per-day coverage basis. If you are admitted to the hospital, you will be required to pay the Part A deductible before you can get coverage for in-patient treatment.
The Part A deductible is $1,556 and once you’ve paid it, your Part A coverage will begin. For the first 60 days in hospital, during each benefit period, you won’t have to pay any coinsurance amounts. However, after 60 days you’ll be liable for a $322 coinsurance amount for days 61- 90.
Knee replacement surgeries usually don’t require extended hospital stays so if you are treated as an inpatient, the only costs you’ll need to cover will be your deductible amount and your monthly premium if you don’t qualify for premium-free Medicare Part A.
Medicare Part A Premiums
Most people who have contributed toward Medicare through taxes do not have to pay for Part A coverage. However, if you haven’t paid Medicare taxes for at least forty quarters, you may have to buy Medicare Part A coverage.
The amount you pay will depend on how much you’ve contributed towards Medicare over the years.
You can get premium-free Part A at 65 if:
You already get retirement benefits from Social Security or the Railroad Retirement Board.
You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.
You or your spouse had Medicare-covered government employment.
If the above does not apply to you, then here’s how much it will cost per month based on your previous contributions.
|Number of Months Contributed||Part A Premium (Per Month)|
|Less than 30 quarters||$499|
Different Types of Knee Surgeries
One of the most common types of knee surgery is total knee replacement. This type of surgery involves replacing the entire knee joint with artificial parts.
Total knee replacement is a very effective surgery, and it typically leads to a significant improvement in pain and function. However, it is an invasive surgery, and it requires a long period of rehabilitation.
Another common type of knee surgery is partial knee replacement, also known as unicompartmental knee replacement.
Partial knee replacement is less invasive than total knee replacement, and it typically has a shorter recovery period.
However, it is not as effective as total knee replacement in reducing pain and improving function. Finally, there is revision knee replacement surgery, which is performed when a previous knee replacement has failed.
Revision surgery is much more complex than either total or partial knee replacement, and it typically has a longer recovery period. However, it can be very effective in restoring pain-free movement to the joint.
Remember that Medicare will only cover a knee replacement surgery if it is deemed to be medically necessary.
What Is the Process of Getting My Knee Replacement Procedure Approved by Medicare?
You’ll first need to go to your physician who will then recommend that you see a knee specialist for further examination.
The knee specialist will then give their recommendation to Medicare that you require knee replacement surgery.
Medicare will review the recommendation and then make a decision on whether or not they will cover the procedure.
If they approve your surgery, then you can book an appointment to have the surgery done. If they reject your application, you can appeal their decision.
Causes for Knee Replacement Surgery
There are many reasons why a person might need knee replacement surgery. The most common cause is osteoarthritis, which results from the breakdown of cartilage within the joint.
Arthritis of the knee can be caused by several things, including wear and tear on the cartilage that involves:
The bones in the joint.
Inflammation of the joint lining.
Problems with the alignment of the bones in the joint.
There are also other causes which include rheumatoid arthritis, psoriatic arthritis, and post-traumatic arthritis.
Knee replacement surgery may also be recommended if you have sustained an injury that isn’t healing on its own and which isn’t responding positively towards less invasive treatments such as physiotherapy.
However, like all major surgeries, it carries certain risks which your doctor will discuss with you prior to having the procedure done.
Your surgeon also will consider your age, activity level, and other factors when making a recommendation. Knee replacement surgery can provide excellent pain relief and improve function in most people who undergo the procedure.
What Else Does Medicare Cover?
If you’re interested in learning more about what Medicare covers, be sure to read our other coverage articles:
What Is the Cost of Knee Replacement Surgery?
The cost of knee replacements will depend on your surgeon and the type of surgery they will be performing.
More invasive and complicated knee replacements will generally cost more than partial knee replacement therapy.
You can expect to pay anywhere from $15,000 to $70,000; however, the price may be more if you require significant rehabilitation or corrective surgery afterward.
The high cost of a knee replacement surgery means that getting the right coverage to help you pay for this procedure is crucial if you don’t want to end up with medical debt that takes years to pay off.
If you’re interested in finding a health insurance plan that will help you cover knee replacement surgeries and other expensive treatments you might need in future, reach out to a licensed insurance agent today.
What about Medicare Advantage Coverage for Knee Replacement Surgeries?
There are some Medicare Advantage Plans that do offer coverage for knee replacement surgery, but these plans typically require a higher monthly premium.
However, you should look at the cost of getting a knee replacement and compare it to the potential cost you might have to pay in premiums each month before you decide on getting additional coverage.
For example, let’s say you join a Medicare Advantage Plan that costs you $159 per month on top of your Medicare Part B premiums. You might be paying more for coverage; however, if you ever need to undergo a knee replacement surgery, you know you’ll be covered in full by your plan.
Tips for Choosing a Medicare Advantage Plan
Do your research: Whether you decide to investigate companies on your own or use a trusted partner to do your research for you, looking at various Medicare Advantage Plans is a smart idea.
Compare the costs and benefits when you decide: While many people are motivated by cost alone, you should also look at the benefits that the different Medicare Advantage Plans might be able to offer you.
Look at reviews before signing up: Check out the Medicare Advantage Plans’ star rating and be sure to look online for member reviews.
Keep important enrollment dates in mind: You can’t sign up for a Medicare Advantage Plan at any time throughout the year. There are specific enrollment periods which you should take note of if you want to avoid disappointment and be accepted by your preferred Medicare Advantage Plan.
Where Can I Learn More about Medicare Coverage?
Getting knee replacement surgery can be a life changing procedure that can improve mobility and your overall quality of life. However, the cost of getting this procedure means that most people will need some sort of health insurance to pay for the costs.
Thankfully, Medicare does cover knee replacement surgeries that are deemed to be medically necessary. If you follow the correct procedure to get approval, you should be able to get your procedure covered by the federal health program.
If you’d like to speak to a Medicare agent about your options and want to figure out if there is a plan that is right for you, give PolicyScout a call on 1-888-912-2132 or send an email to email@example.com to get assistance.