Medicare typically covers hip replacement surgery, providing a doctor confirms the procedure is medically necessary.
Hip replacement surgery could help someone walk easier and lead a healthier life. The Agency for Healthcare Research and Quality reports the completion of more than 400,000 hip replacements each year in the United States.
In this article, we give an overview of which Medicare plans cover hip replacement and what the surgery involves. Then we provide details of each separate plan coverage, eligibility, and costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Original Medicare and Medicare Advantage plans provide help with the costs of hip replacement surgery. Medicare Part D provides coverage for the prescription drugs that someone needs for their recovery at home.
An individual will also have out-of-pocket expenses such as deductibles and copayments. If someone has a Medicare supplement (Medigap) plan from a private insurance company, the plan could help toward costs.
Doctors use the term total hip arthroplasty for hip replacement surgery. The surgery involves replacing a damaged hip joint with an artificial joint. It is an option for people who have used other treatments and pain relief without positive effects.
Surgeons can use a traditional or minimally-invasive surgical technique. The primary difference between these methods is the incision length. The conventional technique requires a 6 to 8 inch cut along the hip joint, whereas the minimally-invasive technique may use one or two smaller cuts.
For either type of surgery, an individual needs general or spinal anesthetic. During the surgery, the surgeon cuts through the thigh bone and removes any damaged tissue and the damaged hip joint. Next, they attach an artificial joint to the thigh bone with surgical cement or screws. After the surgeon replaces the joint, they close the muscles and skin, and may insert a drainage tube.
Original Medicare (Part A and Part B) covers various costs involved in hip replacement surgery. Medicare Advantage plans have to match this level of coverage. A Medigap plan may also help with costs.
More details are shown below.
Medicare Part A
During an inpatient stay at a Medicare-approved hospital, Medicare Part A, which is hospital insurance, provides coverage for certain expenses:
- a semi-private room with a private bathroom
- drugs for pain relief, anti-inflammatory medication or other prescription drugs while an individual is in the hospital
- nursing care
Sometimes, people need more time to recover from their surgery and will move into a skilled nursing facility (SNF). Medicare Part A covers the first 100 days of a stay in an SNF, including physical therapy (PT).
Medicare Part B
Before someone has hip replacement surgery, they will require several minor outpatient procedures to prepare for the procedure.
First, a general physical examination will check if a person is healthy for the surgery. At this point, they will need a full hip examination, and may need blood tests, radiography, or an MRI. Medicare Part B contributes to these outpatient costs.
After surgery, Medicare Part B may cover physical therapy as an outpatient, plus cover the costs of durable medical equipment (DME) such as a cane or walker.
In some cases a person may be able to have hip replacement surgery at an outpatient surgical facility, which means they will go home the same day as the surgery. Medicare Part B provides coverage for those costs.
Medicare Part D
Private insurance companies offer Medicare Part D plans that cover prescription drugs someone needs while at home. Medicare Part A only covers drugs as an inpatient.
Typically, Part D covers the prescription drugs needed during a person’s recovery from hip replacement surgery. These drugs could include:
- pain management medications, such as non-steroidal anti-inflammatories or acetaminophen
- blood thinners to prevent clotting, such as warfarin
- antibiotics if the surgical incision becomes infected
- anti-inflammatories if there is excess inflammation
Private companies sell Medigap policies. The plans are designed to help fill the “gaps” in original Medicare coverage. If a person has a Medigap policy, they may get help with some costs.
Both Part A and Part B of original Medicare or Medicare Advantage plans usually cover hip replacement surgery if a doctor confirms the surgery is medically necessary.
The price of hip replacement surgery in the U.S. varies between $30,000 to $112,000, according to the American Association of Hip and Knee Surgeons.
An individual should contact their doctor to find out more about the cost of their hip replacement surgery. Generally, the amount a person with Medicare coverage has to pay is affected by having met deductibles and premiums.
Medicare part A usually pays 100% percent of the remaining costs after payment of the deductibles and premiums. Medicare Part B pays 80% leaving a person to pay the remaining 20%, plus the deductable and premiums. A person can check if they have met their deductibles.
People with arthritis or other damage to the hip joint may benefit from hip replacement surgery. Medicare typically covers hip replacement surgery if the procedure has been deemed medically necessary.
The amount Medicare contributes depends on several factors, including a person’s Medicare plans, the hospital and outpatient fees, and the state in which the surgery takes place.
People should confirm potential costs with their doctor and hospital before surgery.