Medicare parts A and B cover knee replacement surgery that a doctor considers medically necessary.
Part A covers the in-hospital treatment, including knee replacement surgery and time spent recovering as an inpatient. Part B covers other medical care, such as follow-up consultations and outpatient visits.
Different out-of-pocket costs a person has to pay depends on which part of Original Medicare is funding the care.
According to the Agency for Healthcare Research and Quality, more than 750,000 knee replacements take place each year in the United States.
This article explains the costs of knee replacement surgery, the alternatives to knee replacement 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.
Knee replacement surgery is also known as total knee replacement (TKR). In this article, we look at how Medicare covers TKR and give an idea of the potential costs of this surgery.
Many factors contribute to the total cost of this major surgery. These include:
- the length of time the operation takes
- the type and quantity of anesthesia used
- the number of imaging scans a doctor takes before, during, and after the procedure
- any medications prescribed for pain relief, to prevent infection, and to decrease the risk of blood clots
- number of inpatient hospital days following the surgery
- physical therapy services during recovery
With so many different elements involved, it can be challenging to predict the cost of TKR surgery before treatment begins.
Ahead of the operation, people should talk to the surgeon or clinic to find out the expected costs of surgery and aftercare.
Costs will also vary depending on whether a person is an inpatient or an outpatient. People expecting to stay in the hospital will need to factor in the price of accommodation and overnight monitoring.
For inpatient stays, Medicare Part A and Part B both cover specific costs.
Part A coverage
Medicare Part A covers the cost of knee replacement surgery and its associated hospital costs. An individual must have met their Part A deductible of $1,408 in each benefit period before Medicare starts paying.
No coinsurance applies as long as a person stays in the hospital for less than 60 days in each benefit period. A benefit period starts the day a person enters a hospital as an inpatient and lasts for 60 days.
Medicare Part A covers hospital services such as:
- general nursing
- medication while the individual stays in the medical facility
- other inpatient hospital services, such as imaging scans
- a semi-private room
Part B coverage
Medicare Part B covers medical costs, including most doctor’s visits before and after the surgery.
It also covers services that help the individual recover from their knee replacement surgery, such as physical therapy sessions.
If a doctor recommends that the patient uses a walker or other type of durable medical equipment, Medicare Part B covers the cost.
An individual will be responsible for out-of-pocket expenses associated with the surgery, including the Part B deductible of $198 and 20% coinsurance.
Part D coverage
Medicare Part D covers prescription drugs. Generally, this part of Medicare covers the medications that a person takes at home following surgery.
Following knee replacement surgery, a doctor may prescribe medicines, including antibiotics, anticoagulants, or painkillers.
A deductible, copayment, or coinsurance may apply, depending on the plan.
Medicare Part A does not cover outpatient surgical costs. Instead, Medicare Part B provides coverage.
Most people receive knee replacement surgery on an inpatient basis. However, Medicare also covers outpatient knee replacement surgery, where an individual stays in a medical facility for less than 24 hours.
Medicare Part B would also cover:
- the costs of doctor services
- a cane, walker, or other 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 knee replacement surgery, including the Part B deductible of $198 and 20% coinsurance.
Medicare Part D prescription drug program should cover any necessary medications that a doctor prescribes following knee surgery.
Doctors sometimes recommend outpatient knee replacement instead of traditional inpatient knee replacement.
An individual may choose between an ambulatory surgical center (a center where people undergo surgery but stay no longer than 24 hours) and a hospital outpatient department as their healthcare provider.
The surgical procedure is the same for inpatients and outpatients. However, the surgical preparation, length of hospital stay, and location of post-operative recovery are different for outpatient surgeries.
A doctor may recommend that an individual stays in a skilled nursing facility (SNF) for a limited period after their knee replacement surgery.
Medicare Part A covers the first 20 days of care in an SNF. However, the individual needs a qualifying hospital stay of at least 3 days before their admission into the SNF.
Between days 21 and 100, a daily coinsurance of $176 applies. After this period, the insured person is responsible for all SNF costs.
Individuals can confirm if they have met their deductibles for both Part A and Part B by logging into MyMedicare.gov or by checking their last Medicare Summary Notice.
An individual must meet these deductible amounts before Medicare pays for knee replacement surgery and aftercare.
Medicare Part C is also called Medicare Advantage. Private companies administer these bundled plans, and they must include coverage from Parts A and B. For this reason, Medicare Part C will fund knee replacement.
Many Medicare Advantage plans offer additional benefits, such as coverage for bathroom grab bars and home meal delivery during recovery from surgery.
The out-of-pocket costs for Medicare Advantage plans may be lower than with Medicare Parts A and B, depending on the insurer.
An individual should consult their plan documents to find out about the costs associated with knee replacement surgery and exactly what their plan covers.
A doctor may recommend alternatives to surgery for knee issues. Medicare 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 individuals 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 portion of the knee. This can lead to uneven wear and causes 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.
Unloader knee braces consist of molded foam and steel struts that limit the sideways motion of the knee. They transfer the load of the knee away from the painful area of the knee joint.
An article in The Surgery Journal recommends that doctors recommend the use of uploader knees braces before they consider surgery for people with severe knee osteoarthritis.
Hyaluronic acid is a natural lubricant that supports the fluid of healthy joints and eases movement. Viscosupplementation involves a doctor injecting hyaluronic acid into the knee joint between the bones.
This relieves pain and can improve a person’s range of movement. Treatments last around 6 months, according to Johns Hopkins Medicine.
If a doctor recommends knee replacement surgery, then Medicare should cover the costs. Part A and B pay for different inpatient costs, and Part B accounts for outpatient procedures, aftercare, and consultations.
Part D covers prescribed medications to support recovery unless a person receives it while staying in the hospital.
Different out-of-pocket expenses apply for each part. An individual should check with Medicare to ensure they understand their out-of-pocket costs for a specific procedure.
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