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Medicare Cover Knee Replacement: How Much Does It Cost?

Medicare knee replacement

Our joints wear out over time as we get older, but being overweight and having an injury can speed up the process. The knee joint, in particular, is one of the most prone to wear and tear over time, and when this happens, mobility may become severely restricted. Let’s find out how Medicare cover knee replacement.

Key Points

  • A knee replacement (arthroplasty or a complete knee replacement) is a surgical procedure that helps knee-related patients who have not found relief from their symptoms by alleviating pain, improving mobility, and more.
  • If a total knee replacement is medically necessary, most of the costs are covered by Original Medicare. Whether the procedure is an inpatient completed in an outpatient facility will affect prices.
  • Medicare Advantage plans will also often cover the costs associated with a knee replacement surgery.
  • Plans for Medicare supplement insurance could also cut the cost of knee surgery.

Thankfully, advances in knee replacement surgery over the past few decades have allowed patients to undergo minimally invasive surgeries with quicker recovery times and more durable replacement parts. This is fantastic news for older Americans since fewer of them will experience mobility problems and be able to live well for longer. The materials used in current knee replacements are more precisely developed and can be tailored to fit each patient, resulting in fewer follow-up appointments and less time and money spent by medical staff.

A knee replacement is what?

A surgeon replaces the knee joint during a treatment known as a knee replacement (also known as an arthroplasty) or a total knee replacement.

Knee replacements provide the following advantages: They lessen knee discomfort, improve mobility, increase strength, and improve stabilization.

What Is the Price of a Knee Replacement?

Knee replacements are costly, typically costing $50,000 or more without insurance.

The total cost of a knee replacement will vary depending on several variables: 

  • If it is an inpatient or outpatient surgery
  • Prescription drugs may be required to relieve pain, prevent blood clots, etc.
  • Prescription medication needs
  • Anesthesia kind and dosage
  • An inpatient hospital stay (if applicable)
  • X-rays and physical treatment

Medicare: Does Knee Replacement Surgery Qualify?

Medicare provides the majority of the cost of knee replacement. However, for Medicare to pay for the treatment, a medical practitioner must determine the knee replacement to be medically necessary. Additionally, a patient should continue to budget for out-of-pocket costs.

Average costs for Medicare

A typical ambulatory surgery center treatment will cost $8,063 to complete, leaving Medicare recipients to pay an additional $2,015 in costs.

Medicare will pay $11,886 for knee replacement surgeries performed in an outpatient setting at a hospital, leaving beneficiaries to pay the remaining 20% or $1,748 on average.

Over and above the actual treatment, knee replacements are expensive—prescription drugs, walkers, knee braces, physical rehabilitation, subsequent medical appointments, and more. These are covered by both Medicare Part A and Part B (hospital insurance & medical insurance)

Part A of Medicare

Hospital insurance under Medicare is provided under Part A. Once individuals have reached their Part A deductible, Medicare Part A starts to pay for inpatient services. Most patients undergo knee replacement surgery as inpatients and spend a few days in the hospital following the procedure.

Part B of Medicare

Medicare’s medical insurance is known as Part B. Outpatient services are covered by Medicare Part B. A knee replacement procedure performed as an outpatient or without an overnight stay in the hospital is now covered by Medicare. As long as the beneficiary has fulfilled their yearly deductible, Medicare Part B will pay up to 80% of the allowed costs for a knee replacement. The deductible is $217 in 2022.

Part D of Medicare

Medicare’s prescription drug coverage is provided under Part D. Prescription medications may be required after knee replacement surgery to treat pain, avoid blood clots, etc. Medicare consumers can verify which medications are included in the plan’s formulary even though prescription drug plans will differ in what they cover.

Your out-of-pocket expenses

You will be responsible for paying your Part B deductible and 20 percent coinsurance out-of-pocket for your knee surgery (remaining cost).

Verify the precise charges for the surgery and the post-operative treatment, including pain medication and physical therapy, with your doctor and the hospital.

Medication may be an additional expense if you have not chosen to participate in the Medicare Part D prescription drug program.

Part D of Medicare

The necessary drugs for pain treatment and rehabilitation should be covered by Medicare Part D, an optional benefit for everyone with Medicare.

Supplemental Medicare Plan (Medigap)

Depending on the specifics, your Medicare supplement plan may cover out-of-pocket expenses if you have one.

Plan for Medicare Advantage (Part C)

Your out-of-pocket expenses with a Medicare Advantage plan could be less than they would be with traditional Medicare, depending on the specifics of your plan. Part D is a component of many Medicare Advantage plans.

Do Medicare Advantage Plans cover Knee Replacement Procedures?

Private insurance businesses that have received Medicare’s approval to offer health plans are known as Medicare Advantage (MA) plans. Medicare Part A & Part B coverage are combined in MA plans, commonly known as Medicare Part C. Because Original Medicare covers knee replacement operations, MA plans offer the same services.

Despite this, Medicare Advantage plans could offer extra benefits in addition to those covered by Original Medicare. Prescription medicine coverage and assistance with premium payments are two examples of this. These advantages might make a patient’s out-of-pocket knee replacement expenses less expensive.

Are There Any Additional Medicare Benefits to Assist with Knee Replacement Costs?

Other elements of the government-run Medicare program can reduce out-of-pocket expenses. Among these are Medicare supplement programs.

Plans for Medicare Supplemental Insurance

The term “gaps” in Original Medicare describes the coverage provided by Medicare supplement insurance plans, often known as MedSupp or Medigap.

A Medicare supplement plan is in addition to Original Medicare; policyholders should still anticipate that their Medicare plan will cover roughly 80% of the cost of a knee operation, leaving only 20% of the cost as their responsibility unless they have already reached their annual deductible.

Medigap policies, like MA plans, may lower out-of-pocket expenses. Cost coverage, however, is entirely based on the particular plan and insurance provider.

The cost of knee replacement surgery under Medicare

The expense of knee replacement surgery is one of the major worries that seniors and Medicare participants under the age of 65 who qualify because of a disability have. Most of the time, Medicare covers knee replacement surgery and necessary follow-up care.

You must first undergo screenings and treatment from your primary care physician, who participates in Medicare and accepts an assignment, to be deemed a strong candidate for knee replacement surgery. You can be referred to an orthopedic specialist by your primary care physician. Because they are done outside of a hospital setting, these doctors’ services are covered by Medicare Part B. Suppose a doctor determines that surgery is the best course of action. In this instance, the treatment will be administered in a surgical facility and should be covered by Medicare Part B as an outpatient service. Part A will assist in paying for your hospital stay if you are admitted for the procedure.

Medicare Protection during Recuperation

Medicare Part A will pay for a brief stay in a skilled nursing facility if a temporary quick in a medical setting is necessary. While residing in a skilled nursing facility, beneficiaries of Medicare may also get drugs, clinical services, and tests; each of these services may fall under Medicare Part A or B, depending on the treatment and the attending specialist.

After your surgery, you’ll probably need follow-up treatment and monitoring to see if the procedure was successful or if any remedial action is needed. These visits will once more be covered under Medicare Part B. The prescription drug benefits described in Medicare Part D are likely to apply to any medications administered to address pain, prevent infection, or strengthen tissue.

Understanding the Deductible in Your Plan

It is vital to remember that patients must satisfy their plan’s deductible for treatments to be reimbursed for Medicare coverage and knee replacement surgery. Your plan will determine your out-of-pocket expenses, but it may also be impacted by particular difficulties or complexities associated with your needs. The choice between full or partial knee replacements may also need to be discussed, as each treatment will have varied expenses and may need the services of various specialists.

Make sure you comprehend your plan’s benefits before surgery because knee replacement surgery can be pricey on your own, like all other major surgeries. You & your doctor can find alternate therapies using orthopedic support systems until the appropriate time to undertake the procedure if surgery is not budgeted.

Substitutes for knee surgery

Medicare may additionally pay for the following in addition to knee replacement surgery:

  • Viscosupplementation: Hyaluronic acid, a lubricant, is injected during this treatment into the space between the two bones of the knee. A vital component of joint fluid in healthy joints, hyaluronic acid aids in lubricating injured joints, which reduces discomfort, improves movement and slows the course of osteoarthritis.
  • Nerve treatment: To relieve pressure and lessen pain, this technique involves the nonsurgical repositioning of pinched nerves in the knee.
  • Knee brace for unloaders: This knee brace restricts side mobility of the knee and applies pressure to three spots on the thighbones to ease the pain. As a result, the knee is forced to bend away from the painful joint. Medicare covers knee braces that are considered medically necessary by your doctor.

Popular knee treatments that Medicare does not currently cover include:

  • Stem cell treatment: This method includes infusing stem cells into the knee to regenerate cartilage.
  • Plasma rich in platelets (PRP): To promote natural healing, this treatment includes injecting platelets extracted from the patient’s blood.

What is covered by the price of a knee replacement?

Knee replacement is a surgical treatment, and like all major surgeries, it depends on various factors to determine how much it will ultimately cost. The following elements affect how much a knee replacement costs:

Time spent in the operating room; anesthesia type and dosage; X-rays during and following the treatment; medications to treat pain, prevent infection, and lower the risk of blood clots; days spent recuperating in an inpatient hospital; physical therapy services to help you strengthen your knee.

Once you have met your Part A deductible under Original Medicare, Part A will pay for your inpatient stay for a knee replacement. According to the Mayo Clinic, most patients stay in the hospital for only a few days following surgery, so you shouldn’t typically be concerned about any Part A coinsurance costs.

Although most knee replacements are performed as inpatient procedures, Medicare began to pay for outpatient knee replacements in 2018. Part B will pay for your knee surgery if your doctor determines that you are a candidate for outpatient surgery. After meeting your Part B deductible, Part B may cover up to 80 percent of all authorized knee replacement costs.

What should I consider when calculating the cost of knee surgery after I leave the hospital?

To control your discomfort and lower your risk of blood clots or infection, you can be given prescription drugs to take home. You and your surgeon will likely schedule one or more follow-up appointments. You could also require physical or rehabilitation therapy for a few weeks following the treatment.

While Part B typically covers 80% of all permissible expenditures for all medically required doctor visits and any physical or occupational therapy services you require for surgery, Original Medicare often does not cover prescription prescriptions you take at home. If your physician prescribes a cane or walker for you throughout your recovery, Part B often covers these things as well. Discussing your post-operative care with your doctor is smart, so brilliant to know what to anticipate and can better budget your out-of-pocket costs.

After your knee replacement, your doctor might occasionally advise a temporary stay in a skilled nursing facility. Before admission, you must try a stay in the hospital for three days to qualify for Part A coverage of skilled nursing facilities. If your stay is insured, the first 20 days of skilled nursing facility care are provided at no cost; days 21 and up incur a daily coinsurance fee.

If you’re thinking about having an outpatient knee replacement, be careful to discuss the healing process with your doctor because there won’t be a qualifying hospital stay for skilled nursing facility benefits. After an outpatient knee replacement procedure, you could have to cover the price of skilled nursing care on your own.

What are additional Medicare benefits offered to cover the cost of knee surgery?

A covers all or a portion of your out-of-pocket costs for a knee replacement under Part A and Part B, excluding premiums. Your Medicare Supplement Plan might pay your Part A and Part B deductibles and coinsurance amounts, depending on your chosen plan. However, remember that Medicare Supplement Plans typically do not pay any out-of-pocket expenses for prescription medications that Medicare does not cover.

This is how Medicare recipients are covered for prescription drugs. Stand-alone Medicare Advantage Plans Private insurance businesses that provide Medicare Part D Prescription Drug Plans can offer a wide range of plan benefits, deductibles, and cost-sharing arrangements. Each plan may handle the cost of a knee replacement and related costs slightly differently. Before your procedure, carefully read the plan documentation to help you determine how much your out-of-pocket expenses for knee surgery will be.

The prescriptions you take at home are typically covered if you have a Medicare Part D Prescription Drug Plan, either in addition to Original Medicare or as a component of a Medicare Advantage plan. You could pay a deductible, copayment, or coinsurance sum for some prescriptions.

FAQs

What makes someone eligible for a knee replacement?

The most frequent justification for knee replacement surgery is to address extreme osteoarthritis-related pain. Most people who require knee replacement surgery struggle to walk, climb stairs and get in and out of chairs. Some people may have knee pain while they are not moving.

Does Medicare Cover Knee Replacement?

The most frequent justification for knee replacement surgery is to address extreme osteoarthritis-related pain. Most people who require knee replacement surgery struggle to walk, climb stairs and get in and out of chairs. Some people may have knee pain while they are not moving.

What portion of a knee replacement does Medicare cover?

While Medicare will typically cover 75% of the cost of your knee replacement surgery, it’s important to remember that there may be a long wait if you choose to have the procedure done through the public system.

How long are you hospitalized following a knee replacement?

You might spend 2-3 days in the hospital, depending on how well you heal and the kind of knee replacement you get. Partial knee replacement patients usually stay in the hospital for a shorter period. Some facilities might allow you to leave the hospital on the same day.

Does Medicare Cover Knee Replacement?

Fifteen years following surgery, more than 90% of patients with total knee replacement are still in good health.

Visit our website NewMedicare.com to learn more.

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