Every year, nearly 800,000 Americans have knee replacement surgery. Debilitating knee pain and instability can make tasks like walking and climbing stairs difficult. Medicare Parts A, B, and D provide coverage for the evaluation, treatment, and rehabilitation related to knee replacement surgery. Surgery can be expensive, and most beneficiaries question if Medicare covers knee replacements and what it will cost.
Admission as an inpatient or outpatient affects your Medicare coverage for knee replacements. Clarify your admission status with your provider ahead of time.
Medicare Part B helps pay for outpatient costs at 80% of the Medicare-approved amount after you meet your deductible. This can include outpatient surgery.
Your doctor will typically prescribe medications for you after surgery. Medicare Part D provides coverage for prescription medications.
This article will explain Medicare coverage for knee replacement surgery and the importance of asking questions along the way.
What is knee replacement surgery?
A surgeon will replace your entire knee joint during a total knee replacement surgery. This surgery is also called a total knee arthroplasty. In some cases, only a partial knee replacement is necessary.
Knee replacements are major surgery and can be done in either outpatient or inpatient settings. Successful surgery can alleviate pain and instability from deteriorated knee joints. Osteoarthritis, obesity, and a history of sports injuries account for most surgeries. Surgeons will resurface your joint and create a new artificial joint. Knee replacements can last over a decade, improve mobility, and decrease pain.
Post-op, you will have at least one follow-up visit with your physician. Physical therapy visits may be in your home or an outpatient location; they are essential to improve recovery times.
In the past, knee replacement surgeries required an inpatient hospital stay, but now they are also done in ambulatory surgery centers or outpatient departments of hospitals. The surgery is the same regardless of the facility, but Medicare coverage changes based on where the procedure is performed and your admission status.
Knee replacement cost: what is included
If you fail nonsurgical treatment for knee pain and need knee surgery, Medicare will typically cover these services under Medicare Part A or B. Medicare Part D covers prescription medications when you go home.
Regardless of the facility, a knee surgery care plan commonly includes the following:
- Medications to decrease the risk of blood clots (anticoagulants)
- Antibiotics given during surgery and possibly after surgery
- Physician appointments before and after surgery
- Diagnostic imaging pre and post-op, like X rays
- Operating room and recovery room services
- Physical therapy services
- Medications for pain
- Anesthesia services
- Nursing services
Some people will also need the following:
- A longer inpatient stay or skilled nursing facility admission.
- Durable medical equipment such as a cane or walker.
Does Medicare cover knee replacements?
If you are enrolled in Original Medicare, you will have some coverage for a knee replacement. However, it gets tricky to determine precisely which part of Medicare covers which services, and to complicate it a little more, some services may overlap. Importantly, you will need to know if you are scheduled for surgery as an inpatient or outpatient, as this can impact your costs.
Medical policies are filled with terms and conditions. When facing major surgery and related recovery costs, communicate with your doctors and Medicare representative to get the most up-to-date information on benefits and costs.
Medicare Part A
Medicare Part A covers up to 60 days of an inpatient hospital admission at 100% if you have met your $1600 benefit period deductible for 2023. Knee replacements generally do not require extended inpatient stays. Sometimes if you have difficulty getting safely back on your feet, a physical therapist and your doctor may recommend additional rehabilitation at a skilled nursing facility.
Again, these are not usually extended stays, and Medicare Part A covers SNF benefits at 100% up until day 20. However, Medicare requires a three-day inpatient hospital admission (qualifying event) before approving an SNF stay.
You could be admitted to the same hospital for the same surgery done by the same team but designated as an outpatient admission by the facility. So make sure to ask. Inpatient stays are usually longer, over two midnights, but not always; it depends if the doctor writes an inpatient order. You would not normally know this because the care is essentially the same; it is a billing process, but inpatient costs can be higher. Observation status can be changed to inpatient if you experience complications.
Medicare Part B
Ambulatory surgery centers are not general hospitals; typically, there are no overnight stays, and people who admit for surgery are discharged home the same day. Outpatient centers within a hospital work similarly; you could be admitted for same-day surgery. However, if they keep you overnight but for less than 24 hours, you would still be in outpatient or observation status. You may be able to choose between an inpatient, an ambulatory center, or an outpatient hospital setting, which can affect your out-of-pocket responsibility.
After you pay your $226 Part B deductible for 2023, Medicare Part B will cover 80% of the Medicare-approved amount. Your responsibility is 20% of the approved amount. Ask if your doctor, the facility, and the anesthesiologist accept the Medicare-approved amount as full payment. If not, you could end up paying the difference.
According to the Medicare.gov procedure price look-up, you can expect to pay an average of $2,054 at an ambulatory surgical center and $1,818 at a hospital outpatient facility for total knee arthroplasty (total knee replacement).
Medicare Part D
Medicare Part D covers prescriptions your doctor gives you to take home after surgery.
Knee replacement surgery is painful, and pain medications are encouraged, at least in the short term. Managing pain allows you to heal faster and tolerate rehabilitation, including physical therapy and home exercise programs. Major surgery increases the risks of blood clots, which can travel to your legs (deep vein thrombosis), to your brain (stroke), and your lungs (pulmonary embolism).
Your doctor may recommend an anticoagulant or blood thinner to decrease the risk of clots. Depending on the reason for your surgery, your surgeon may prescribe antibiotics. Some knee surgeries are revisions or are done because of an infected prosthesis. Doctors may prescribe antibiotics if needed.
Because Medicare Part D is offered and managed by private health insurance companies, plans can vary. You may have deductibles, copays, and coinsurance on medications. Contact your specific benefits representatives for more information.
Do Medicare Advantage Plans cover knee replacement?
Medicare Advantage Plans are also offered and managed by private health insurance companies. Sometimes called Medicare Part C, these plans must provide beneficiaries with Original Medicare Part A and B coverage. Often Medicare Advantage plans include a prescription drug coverage Part D plan.
With this in mind, Medicare Advantage will help pay costs associated with knee replacement surgery, medications, doctor visits, and therapy. However, they can have different out-of-pocket costs, eligibility criteria, and network stipulations. If you have Medicare Advantage, contact your plan for clarification and additional coverage information.
Does Medicare cover rehab after a knee replacement?
Rehabilitation after knee surgery can occur in a skilled nursing facility, inpatient acute rehab, home health, or an outpatient physical therapy center. A medically necessary inpatient admission to an SNF or rehab facility will be covered under Medicare Part A.
If you are homebound, a physical therapist may visit you at home and provide support to improve strength, endurance, range of motion, gait training, and fall prevention. Physical therapy also includes establishing a home exercise program. Medicare Part A or a combination of Medicare Part A and B covers home health services. Walkers and canes must be ordered by a physician and are covered under Medicare Part B as durable medical equipment.
Outpatient physical therapy visits are covered under Medicare Part B at 80% of the approved amount once you meet your Part B deductible. Medicare will only approve care that is necessary and reasonable. Most people fully recover from knee surgery by about 12 weeks post-operatively.
How much does knee replacement surgery cost without insurance?
If you are considering paying out of pocket for a knee replacement, uninsured prices are affected by your zip code, the type of facility, the reputation and quality of care provided by the facility, doctors' fees, diagnostics, imaging fees, type of joint replacement, and so on. If you have any post-operative complications, your self-pay costs have the potential to increase significantly. Knee replacement surgery could be anywhere from $15,000 to $70,000, with an average cost of $30,000 if there are no complications. Hospitals and providers are often willing to negotiate a discount with self-pay patients.
Some people travel to other countries to have surgery at cheaper prices. However, unless you are familiar with a foreign health system, you should do thorough research before making such a decision.
Who is eligible for total knee replacement?
You may be eligible for knee replacement surgery if you have debilitating knee pain while walking, climbing stairs, or resting. Your doctor may try nonsurgical interventions first. Medicare Parts A, B, and D can help cover costs if you are enrolled and meet the criteria.
What is the average cost of replacing a knee?
When you need knee surgery, there will be costs besides the surgery itself, including doctor visits, physical therapy, durable medical equipment, and medications. The average member cost of a TKA is $2,054 at an ambulatory surgical center and $1,818 at a hospital outpatient facility.
Is knee replacement a disability?
A knee replacement could be a disability if you can no longer work. It will likely depend on how physically demanding your job is and if you have chronic pain. You may be eligible for Social Security Disability Insurance, Long Term Disability, or other aid.