Does Medicare cover knee replacements?

Knee replacements are one of the two most common inpatient surgeries for Medicare beneficiaries (with hip replacements being the other). It is also one of the most expensive procedures. Average costs for hospitalization, surgery, and recovery ranges from $16,500 to $33,000. As such, the procedures cost American taxpayers a staggering amount of money. According to US News, knee and hip replacements in 2014 resulted in $7 billion in hospitalization expenses.

It’s because of this enormous cost that the United States government implemented a new system for Medicare knee and hip replacement procedures in the spring of 2016. The changes are designed to lower costs and increase the procedures’ success rates. However, some surgeons have voiced concerns about the new procedures eventually leading hospitals to discourage surgery for patients who have less of a chance for a good recovery. The new program emphasizes quality over quantity for hospitals and doctors that perform knee and hip replacements. In particular, the emphasis is on reducing costly post-surgical complications.

The changes will largely be invisible to beneficiaries seeking Medicare reimbursements at the start. But due to the new program’s cost and quality targets regarding hospital performance, future knee and hip replacement seekers may find it more difficult to obtain Medicare coverage or reimbursement.

Current coverage for Parts A and B

Currently, Original Medicare Parts A and B will pay for various parts of your knee replacement surgery, provided the surgery is deemed medically necessary by your doctor. Part A will cover your inpatient hospital stay. Part B will handle outpatient services and possibly recovery services mandated by your physician. You will need to pay the Part B deductible followed by 20% of the co-insurance fees. If you have Medicare Part C (sometimes called Medicare Advantage), it provide the same coverage as Parts A and B. Many Part C plans also offer additional coverage. If you anticipate knee replacement surgery in your future, you might want to explore Part C plans if you don’t have one.

If your doctor prescribes antibiotics, anticoagulants, or painkillers following your knee surgery, you may receive coverage for them under Medicare’s Part D prescription drug program. Alternatively, you may opt for for a Medicare Advantage Prescription Drug policy.

It’s important to confirm with your doctor or hospital exactly how much you’ll have to pay for knee replacement surgery. Be sure to check costs for both for the procedure itself and for the usually extensive aftercare that involves physical therapy and possibly pain medication. You should also log in to MyMedicare.gov or view your last Medicare Summary Notice to see if you’ve met your deductibles for both Part A and Part B. You’ll need to pay these deductible amounts before Medicare will cover your surgery and follow up care.

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