Original Medicare, parts A and B, covers many medically necessary surgeries, including shoulder replacement surgery.
Part A, which is hospitalization insurance, covers inpatient costs, while Part B, which is medical insurance, covers outpatient costs, such as doctor visits.
Medicare Advantage (Part C) plans are an alternative to original Medicare and can provide coverage for shoulder surgery. Medicare Part D and Medigap may also provide some coverage.
This article examines what each part of Medicare covers and the out-of-pocket costs. Then, it discusses shoulder replacement surgery and other common shoulder surgeries, as well as alternative treatments.
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.
All parts of Medicare provide some coverage for surgeries that repair or replace the shoulder. The details are below.
Part A and Part B
Part A provides coverage of inpatient surgery, including medications and therapies a person receives during a hospital stay. Because shoulder replacement surgery requires 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 release from the hospital.
Some types of shoulder surgery can be done by a doctor in an outpatient setting. In such cases, Part B would cover the costs of the procedure, along with doctor visits, lab tests, and any durable medical equipment that a person needs.
Following either inpatient or outpatient shoulder surgery, a doctor may recommend physical and occupational therapy. Part B covers these services.
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.
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 often prescribe for people following shoulder surgery.
Medigap is Medicare supplement insurance that pays 50–100% 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 that can pertain to shoulder surgery.
Part A out-of-pocket costs include:
- $1,408 deductible for each benefit period
- 0% coinsurance for first 60 days of each benefit period
- $352 per day coinsurance for days 61–90 of each benefit period
- $704 per day coinsurance for days 91 and beyond
A benefit period starts the day a person enters the hospital and ends the day after someone has been out of the hospital for 60 consecutive days.
Part B out-of-pocket costs include:
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 costs also include monthly premiums, copays, coinsurance, and 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.
Monthly premiums are the only expense associated with Medigap plans.
This website 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 is an option when suggested activity changes and medications do not relieve pain. Doctors consider it a safe, effective means of helping someone with a damaged shoulder joint to resume everyday activities.
Doctors repair some damaged shoulder joints with arthroscopic surgery, while they repair others with open surgery. Arthroscopic surgery involves making small incisions, so it is
The following are common types of shoulder surgery:
- Surgery to repair a rotator cuff tear may be either open or arthroscopic, depending on the extent of the damage.
- Surgery for repeated shoulder dislocation may be either open or arthroscopic.
- Surgery for a severely fractured shoulder is open, and it may require joint replacement.
- Surgery for a shoulder with severe arthritis may also require joint replacement.
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 can strengthen muscles that support the joint, which reduces pain and promotes stability. It can also involve teaching a person activity modifications that result in less strain on the damaged shoulder joint.
Medicare Part B covers outpatient therapy. Costs include 20% coinsurance and $198 annual deductible.
Doctors may prescribe medications to relive pain and inflammation. These may include cortisone shots or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
Medicare Part B covers cortisone shots received in a doctor’s office.
A person with original Medicare can receive coverage of NSAIDs and other medications needed 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. Doctors consider the surgery a safe and 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 offered by Medicare Part D and Medigap.
Medicare covers other common surgeries that doctors use to treat a damaged joint, as well as cortisone shots and physical therapy. The criterion for coverage is that the treatment must be medically necessary.