Medicare parts A and B cover knee replacement surgery that a doctor considers medically necessary.
Medicare Part A covers the in-hospital treatment, including the surgery and the time a person spends recovering as an inpatient. Medicare Part B covers other medical care, such as follow-up consultations and outpatient visits.
The different out-of-pocket costs a person has to pay depend on which part of original Medicare is funding the care.
Most recent data shows that over 750,000 hospitalizations for total knee replacements took place in the United States in 2014. This article explains the costs of knee replacement surgery, the alternatives to the surgery, and what Medicare covers.
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.
A person can have knee replacement surgery as an inpatient or outpatient. Different parts of Medicare cover various aspects of someone’s surgery.
Inpatient knee replacement
For inpatient stays, Part A and Part B both cover specific costs.
Part A coverage
Part A covers the cost of knee replacement surgery and its associated hospital costs. Before Medicare starts paying, an individual must have met their Part A deductible of $1,484 in each benefit period.
A benefit period starts the day a person enters a hospital as an inpatient and lasts for 60 days. No coinsurance applies, as long as a person stays in the hospital for less than 60 days in each benefit period.
Part A covers hospital services such as:
- general nursing
- medication while the person is staying in the medical facility
- other inpatient hospital services, such as imaging scans
- a semiprivate room
Part B coverage
Part B covers costs such as most doctor’s visits before and after the surgery.
It also covers services that help with recovery, such as physical therapy sessions. And if a doctor recommends using a walker or another type of durable medical equipment, Part B covers the cost of the equipment.
A person will be responsible for out-of-pocket expenses associated with the surgery, including the Part B deductible of $203 and 20% coinsurance.
Part D coverage
Medicare Part D covers prescription drugs that a person takes at home following their knee replacement surgery. These could include antibiotics, anticoagulants, or pain relief medications.
The beneficiary may need to pay a deductible, copayment, or coinsurance, depending on the plan.
Outpatient knee replacement
Most people receive knee replacement surgery on an inpatient basis. However, Medicare also covers outpatient knee replacement surgery. This involves the person being in the medical facility for less than 24 hours.
Part A does not cover outpatient surgical costs. Instead, Part B provides the coverage.
Part B would also cover the costs of:
- doctor services
- a cane, walker, or another type of durable medical equipment
- outpatient rehabilitation services, including physical therapy
As with the inpatient surgery, an individual must pay out-of-pocket expenses associated with the outpatient surgery, including the Part B deductible.
A Part D prescription drug program should cover any necessary medications that a doctor prescribes following knee replacement surgery.
Doctors sometimes recommend outpatient surgery instead of the traditional inpatient surgery.
Anyone opting for outpatient surgery can choose between an ambulatory surgical center — where people undergo surgery but stay no longer than 24 hours — and a hospital outpatient department.
The surgical procedure is the same for inpatients and outpatients. The differences involve the preparation for the surgery, the length of the hospital stay, and the location of postoperative recovery.
Doctors also refer to knee replacement surgery as “total knee replacement,” “total knee arthroplasty,” and “arthroplasty of the knee.”
Many factors contribute to the total cost of this major surgery. These include:
- how long the operation takes
- the type and quantity of anesthetic
- the number of scans before, during, and after the procedure
- any medications for pain relief, to prevent infection, and to reduce the risk of blood clots
- how many days a person spends in the hospital after the surgery
- physical therapy services during recovery
With so many elements involved, it can be challenging to predict the cost of knee replacement surgery. However, a person can learn about the anticipated costs of the surgery and aftercare by checking with the surgeon, clinic, or both.
Costs also depend on whether a person has inpatient or outpatient surgery. People expecting to stay in the hospital need to factor in the price of accommodation and overnight monitoring.
A doctor may recommend alternatives to surgery for knee issues. Part B currently covers the following options if a doctor confirms that they are medically necessary.
As the knee joint wears down over time, some people find that this causes pinching in the nerves that run past the knee.
Specialists use computer technology to visualize where the bones compress the nerve. They then relieve the pinched nerve by moving it out of the way. This nonsurgical technique alleviates pressure and reduces pain.
Unloader knee brace
Arthritis in the knee often affects the inside of the joint, which can lead to uneven wear and tear. It can also cause a person’s knees to wobble when they are walking.
This uneven pressure may lead to pain and weakness in the knee, and some people need to use a brace, such as an unloader knee brace, to help.
Medicare Part B usually covers 80% of the cost of an unloader knee brace. It has a molded foam and steel structure that limits the sideways motion of the knee. This helps realign the knee and can reduce pain.
Hyaluronic acid is a natural lubricant that supports the fluid in healthy joints and eases movement. Viscosupplementation is a procedure in which a doctor injects hyaluronic acid into the knee joint between the bones.
This relieves pain and can improve the range of movement. Treatments last around 6 months.
Medicare covers the procedure as a medical necessity — when the underlying condition’s symptoms are clear, and when they significantly affect daily life and have not responded positively to other types of treatment for at least 3 months.
A doctor needs to provide a diagnosis of osteoarthritis of the knee or evidence that excludes any other diagnosis.
If a doctor recommends knee replacement surgery, Medicare should cover the costs. Parts A and B pay for different inpatient costs, and Part B pays for outpatient procedures, aftercare, and consultations.
Part D covers prescribed medications that a person takes home to support their recovery.
Different out-of-pocket expenses apply for each part. A person should check with Medicare to be sure that they understand the out-of-pocket costs before scheduling any procedure.