Original Medicare parts A and B may cover medically necessary shoulder replacement surgery. Medicare Advantage may also offer coverage. Additionally, Part D and Medigap may also provide some coverage.

Medicare Part A, which is hospitalization insurance, covers inpatient costs. Medicare Part B, which is medical insurance, covers outpatient costs such as doctor visits.

Medicare Advantage (Part C) plans are an alternative to Original Medicare. They can provide coverage for shoulder surgery.

Medicare Part D is prescription drug coverage. Medigap is supplement insurance that can help with out-of-pocket costs.

This article examines what each part of Medicare covers for shoulder replacement surgery, including the out-of-pocket costs. It also discusses shoulder replacement surgery and other treatments.

Glossary of Medicare terms

We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:

  • Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
  • Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
  • Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
  • Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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All parts of Medicare provide some coverage for shoulder replacement surgery.

Part A

Part A provides coverage of inpatient surgery, including medications and therapies a person receives during a hospital stay. If shoulder replacement surgery requires inpatient hospitalization, the costs would fall under this part of Medicare.

In addition, Part A covers skilled nursing care for a limited time for people who need it after their discharge from the hospital.

Part B

Some types of shoulder arthroplasty, or joint replacement, are outpatient procedures.

In such cases, Part B would cover the costs of the procedure, along with:

  • doctor visits
  • lab tests
  • any durable medical equipment that a person needs

A doctor may recommend physical and occupational therapy following either inpatient or outpatient shoulder surgery. Part B covers these services.

Part C

Private companies offer Medicare Advantage (Part C), which is the alternative to Original Medicare. It provides all of the coverage of Medicare parts A and B for shoulder surgery. Many plans also include prescription drug coverage.

Part D

Because Medicare parts A and B do not include prescription drug coverage, a person with Original Medicare may wish to buy a Part D plan, which is available from private companies.

Each plan has a list of covered drugs, which includes at least two medications in every commonly prescribed area.

Part D would include medications for pain that doctors may prescribe for people following shoulder surgery.

Medigap

Medigap is Medicare supplement insurance that pays 50% to 100% of Medicare parts A and B out-of-pocket costs. It is available only to a person with Original Medicare.

Someone with an Advantage plan is ineligible for the coverage. Medigap also does not cover out-of-pocket Part D costs.

Each part of Medicare has out-of-pocket costs regarding shoulder surgery.

Original Medicare

Part A out-of-pocket costs include:

  • a $1,632 deductible for each benefit period
  • 0% coinsurance for the first 60 days of each benefit period
  • $408 per day coinsurance for days 61 to 90 of each benefit period
  • $816 per day coinsurance for days 91 to 150

A benefit period starts the day a person enters the hospital and ends the day after they have been out of the hospital for 60 consecutive days.

Part B out-of-pocket costs include:

  • a $174.70 monthly premium
  • a $240 annual deductible
  • 20% coinsurance

Medicare Advantage

Medicare Advantage costs include monthly premiums, copays, coinsurance, and deductibles. These costs vary among plans, and plan rules may require a person to use in-network providers.

A person can use this tool to find a plan.

Advantage plans put a yearly cap on expenses. Once someone’s healthcare costs exceed this cap, they do not pay any additional amount for Medicare-approved services.

Part D

Part D costs also include:

  • monthly premiums
  • copays
  • coinsurance
  • deductibles

The costs differ among plans. A person’s costs also depend on several factors, such as the particular drugs they take and whether they get them from in-network providers.

Medigap

Monthly premiums are the only expense relating to Medigap plans. This online tool can help a person find a Medigap policy.

The shoulder is a ball-and-socket joint, where the ball is the head of the upper arm bone, and the socket is a concave part of the shoulder blade.

In shoulder replacement surgery, a doctor removes the damaged parts of the shoulder joint and replaces them with artificial parts. There are two types of surgery: replacement of the ball alone or replacement of the ball and socket.

Shoulder replacement surgery may be an option when other treatments do not relieve pain. It can be an effective means of helping someone with a damaged shoulder joint to resume everyday activities.

Replacement or surgical repair of the shoulder joint is often a last resort. Doctors may first recommend other measures that Medicare covers, such as physical therapy or medications.

Physical therapy

Physical therapy can strengthen muscles that support the joint, which reduces pain and promotes stability. It can also involve learning modifications to activities that result in less strain on the damaged shoulder joint.

Medicare Part B covers outpatient therapy. Costs include 20% coinsurance and the annual deductible.

Medications

Doctors may prescribe medications to relieve pain and inflammation. These may include cortisone shots or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.

Medicare Part B covers cortisone shots that a doctor administers.

A person with Original Medicare can receive coverage for NSAIDs and other medications necessary for a shoulder condition through a Part D plan.

Someone with an Advantage plan can receive coverage if their plan includes prescription drug benefits.

Both Original Medicare and Advantage plans cover shoulder replacement surgery if it is medically necessary. It can be an effective way to relieve a person’s pain and restore their ability to resume everyday activities.

A person may also want to look at the coverage that Medicare Part D and Medigap offer.

Medicare also covers other treatments doctors use to treat a damaged joint, such as cortisone shots and physical therapy.