Does Medicare Cover Hip and Knee Replacement?
Hip and knee replacements are the most common inpatient surgeries for Medicare beneficiaries. Original Medicare and Medicare Advantage plans help with surgery costs, and Medicare Part D with prescription drugs. You still have to pay deductibles and copayments, but a Medigap plan may help with those.
What Does Medicare Cover with a Hip or Knee Replacement?
Original Medicare — Medicare Part A and Part B — cover a wide variety of costs associated with hip and knee replacement surgery, also called lower extremity joint replacement or LEJR.
A Medicare Part D plan can help cover prescription drugs related to your hip or knee replacement surgery, while a Medicare Supplement (Medigap) plan helps cover the out-of-pocket costs not covered by Original Medicare.
Medicare Advantage plans must cover what Original Medicare does, but may include additional benefits.
Medicare Part A
Medicare Part A is hospital insurance. It covers costs associated with your hospitalization for hip or knee replacement surgery.
Typically, a hip or knee replacement requires you to stay in the hospital for one to four days. Medicare will cover a share of certain approved costs during your stay.
- Drugs that are part of your inpatient hospital treatment
- First 100 days of skilled nursing facility care after being discharged
- Nursing care
- Semi-private room with its own bathroom
Medicare Part B
Medicare Part B is medical insurance. It typically covers doctor visits and medical services. It also helps pay for the medical costs of knee and hip replacements.
- Doctor fees including visits before and after your surgery
- Durable medical equipment such as a cane or walker
- Physical therapy sessions
- Your artificial hip or knee joint
- Your surgery
Medicare will only pay for prosthetics when they are ordered by a doctor or other health care provider approved by Medicare. And the device has to come from a supplier that is also enrolled in Medicare.
Medicare Advantage Plans
Medicare Advantage plans are sold by private insurers and are required to cover everything that Original Medicare does, so your plan will cover at least what Medicare Part A and Part B cover.
But Medicare Advantage plans may also provide benefits that Original Medicare does not cover. These may include nonemergency transportation to doctor appointments or other medical visits associated with your joint replacement.
Some Medicare Advantage plans may also cover meal delivery services while you are at home recuperating from the surgery.
Medicare Part D Prescription Drug Plans
Medicare Part D prescription drug plans are sold by private insurers. Since Medicare Part A only covers medications you receive while in the hospital, a Part D plan can help cover the costs of prescription medicines you may need after your knee or hip replacement.
- Antibiotics to prevent or treat infection
- Anticoagulants (also called blood thinners) such as warfarin
- Anti-inflammatory drugs
- Pain medicine such as NSAIDs (ibuprofen, naproxen, nabumetone, aspirin) and acetaminophen (Tylenol)
Medigap — also known as Medicare supplemental insurance — policies are sold by private companies and can help pay your out-of-pocket costs associated with Original Medicare.
Some, but not all, Medigap policies may pay your Medicare Part A and Part B deductibles along with copayment or coinsurance costs. The amount a policy pays varies from plan to plan.
You should check with your Medigap policy’s administrator to determine what costs are covered.
What Is Your Out-of-Pocket Cost for Hip or Knee Replacement?
While Medicare covers much of the cost for approved hip or knee replacement, you will still have to pay deductibles, copayments and coinsurance.
The amount you owe will depend on the type of Medicare coverage you have.
- Medicare Part A
- You are responsible for paying your Medicare Part A deductible — $1,484 for each benefit period in 2021. The benefit period begins the day you are admitted to a hospital and ends after you have not been readmitted for 60 days in a row.
- Medicare Part B
- You will still have to pay 20 percent of the Medicare-approved cost of the medical device and other medical services. Your Medicare Part B deductible — $203 in 2021 — also applies.
- Medicare Advantage Plans
- The amount varies from plan to plan. You should contact your Medicare Advantage plan administrator to find out how much you will have to pay.
- Medicare Part D
- Your out-of-pocket costs will vary from plan to plan. You should check with your plan administrator to find out your share of the costs. You should also ask your doctor about alternative drugs on your Medicare Part D formulary that may cost you less.
Does Medicare Cover Alternatives to Hip or Knee Replacement?
Medicare covers some but not all popular alternatives to hip and knee replacement surgery.
Remember, if your doctor recommends a knee or hip replacement, not all alternatives may work for your particular situation. Alternatives may not be possible depending on how extensive your joint damage has become.
You should check with your doctor and with your Medicare plan to see if alternatives are covered under your plan.
- Knee Braces
- Covered by Medicare in certain cases. Medicare covers unloader knee braces if your doctor determines they are a medical necessity. These are devices that limit your knees’ side movements, moving knee movement away from the area that causes pain.
- Nerve Therapy
- Covered by Medicare. This is a nonsurgical therapy that shifts pinched nerves in the knee. It is intended to reduce pressure on the nerves, reducing the pain you experience.
- PRP Treatments
- Platelet-rich plasma, or PRP, treatments are not covered by Medicare for hip or knee treatments. PRP treatments utilize your own platelets — tiny blood cells that help your body cause blood clotting to prevent bleeding. The platelets are retrieved from your own blood and reinjected into your body to encourage natural healing.
- Stem Cell Therapy
- Not covered by Medicare for knee or hip treatments. Stem cell therapy injects stem cells into the knee to regrow cartilage — the tough, flexible tissue in your hip and knee joints that can cause pain and possibly lead to hip or knee replacement when it wears out.
- Covered by Medicare. This therapy injects hyaluronic acid — a lubricating fluid found naturally in healthy joints — into the hip or knee joint. This can ease pain and improve movement in the joint as well as slow the progression of osteoarthritis.
You should also check with your plan administrator if you have a Medicare Advantage plan, Medicare Part D prescription drug plan or Medigap policy to see how much your plan will pay and how much you are responsible for if you are having alternative treatments.
5 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services (2021, January 14). Comprehensive Care for Joint Replacement Model. Retrieved from https://innovation.cms.gov/innovation-models/cjr
- U.S. Centers for Medicare & Medicaid Services (2020, November). Major Joint Replacement (Hip or Knee). Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf
- Sherrell, Z. (2020, July 22). Does Medicare Cover Hip Replacement? Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-hip-replacement
- Mayfield, C.K. et al. (2019, December 16). Medicare Reimbursement for Hip and Knee Arthroplasty from 2000 to 2019: An Unsustainable Trend. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31924490/
- U.S. Centers for Medicare & Medicaid Services (n.d.). Prosthetic Devices. Retrieved from https://www.medicare.gov/coverage/prosthetic-devices