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Does Medicare Cover Knee Replacement Surgery Costs?

Justin Mack by Justin Mack | Licensed since 2008
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This article was updated on: 11/16/2016

Knee replacement surgery, along with hip replacement, are the most common types of surgery for those enrolled in the Medicare program, according to the Centers for Medicare & Medicaid Services. More than 400,000 Medicare beneficiaries had knee or hip replacement surgery in 2014, the Department of Health & Human Services reported.

Medicare Part A and Part B (also known as Original Medicare) cover different portions of this procedure and the associated aftercare when it’s determined medically necessary by your doctor. Generally, Medicare won’t cover knee replacement surgery – or any joint replacement – unless other treatments your doctor has prescribed or recommended have not helped your condition.

Original Medicare coverage of knee replacement surgery costs

Under Medicare Part A, your inpatient stay associated with a knee replacement surgery usually can’t exceed the deductible for Part A. Any outpatient services associated with your knee replacement surgery may be considered for payment under Medicare Part B.  You typically have to pay both the Medicare Part A and Part B deductible amounts before Medicare covers its share of costs for these services.

Recovery from knee replacement surgery might involve follow-up office visits, physical or occupational therapy, and other services. Before you have the surgery, you may want to ask your doctor to give you an idea of what kind of post-surgery care you might need so you can plan for it.

Medicare Supplement plan might help cover knee replacement surgery costs

Original Medicare (Part A and Part B) comes with out-of-pocket costs such as deductibles, and copayments. Available from private insurance companies, Medicare Supplement (Medigap) plans may help with these costs; there are ten standardized Medigap plans in most states (Massachusetts, Wisconsin, and Minnesota have their own standardized plans). Each standardized Medicare Supplement plan covers different amounts of these out-of-pocket costs.

If you’re considering getting a Medicare Supplement plan, you need to know that while you can apply for this type of insurance anytime, your acceptance may be guaranteed only during time periods. For example, the Medicare Supplement Open Enrollment Period (a six-month period starting when you’re aged 65 or over and enrolled in Medicare Part B) is a time period when you can typically enroll in a Medigap plan despite any health condition you might suffer from.

Other costs that may be associated with Medicare coverage of knee replacement surgery

Another possible cost you might want to plan for is that of any prescription medications your doctor might prescribe, such as painkillers, anticoagulants, or antibiotics. Medicare Part A may cover prescription drugs you receive as part of your inpatient treatment, while Medicare Part B may cover certain prescription drugs administered to you as an outpatient. But Original Medicare typically doesn’t cover medications you take at home.

A stand-alone Medicare Part D Prescription Drug Plan may help cover your prescription drugs, although not every prescription drug is covered under every plan. Offered by private, Medicare-approved insurance companies, Medicare Prescription Drug Plans maintain their own formularies (lists of covered drugs). If you’re thinking about enrolling in a Medicare plan that includes this coverage, you might want to check the plan’s formulary before you enroll to make sure your prescriptions are covered. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

Medicare Supplement insurance and a stand-alone Medicare Part D Prescription Drug Plan may be options to consider if you’re enrolled in Original Medicare. Another choice you may have is to get your Medicare Part A and Part B benefits through a Medicare Advantage plan. Available from private insurance companies that contract with Medicare, these plans include your Part A and Part B benefits (except for hospice care, which Part A covers), and many plans also include prescription drug coverage (and often other benefits, like routine vision services). You must continue paying your Part B premium, along with any premium the Medicare Advantage plan may charge.

If you have other questions about Medicare coverage, or would like to learn more about your Medicare plan options that may give you more benefits, we would be happy to help. You can use the links below to request a phone call or an email containing personalized information. Of course, you can also shop Medicare plans in your area on your own by clicking the Find Plans button on this page. If you have questions at any point, you can call our licensed insurance agents at 1-844-847-2660, TTY users 711; Monday through Friday, 8AM to 8PM ET. Ask for me by name, or choose to speak to the next available licensed insurance agent. Either way, we will help you get the answers you’re looking for.

This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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