Knee replacement surgery, also called knee arthroplasty, is a common treatment for people dealing with severe knee pain or joint damage. If you’re covered by Medicare, it’s important to understand how much Medicare will pay for the surgery and what costs you might be responsible for.

In this guide, we will answer one of the most common questions: Does Medicare Advantage cover knee replacement surgeries? We will also discuss what out-of-pocket expenses to expect and how to navigate your options with confidence.

Does Medicare Cover Total Knee Replacement?

Yes, Medicare generally covers total knee replacement surgery if your doctor determines it’s medically necessary. Coverage depends on how and where the surgery is performed:

• Inpatient Surgery (Part A): If your knee replacement requires a hospital stay, Medicare Part A helps cover your hospital costs, the surgery itself, and related inpatient services. You are still responsible for the Part A deductible and any coinsurance if your stay extends beyond 60 days.
• Outpatient Surgery (Part B): Many total knee replacements are now performed as outpatient procedures, meaning you go home the same day. In this case, Medicare Part B covers the surgery, doctor visits, and outpatient physical therapy afterward. You’ll pay the Part B deductible plus 20% of the Medicare-approved amount for services.

Regardless of where the surgery takes place, Medicare only covers procedures considered medically necessary. Your doctor must document that your knee condition significantly limits your ability to move or perform daily activities, and that other treatments, such as medications or physical therapy, haven’t been effective.

If you have a Medicare Advantage (Part C) plan, your coverage will include everything Original Medicare offers, but you may also have access to additional benefits like reduced out-of-pocket costs, enhanced rehab services, and prescription drug coverage. Coverage details vary by plan.

Medicare Coverage for Knee Replacement in Different Settings 

Depending on whether your knee replacement surgery is inpatient or outpatient, Medicare covers different aspects of the procedure. Inpatient surgery, typically requiring an overnight hospital stay, is covered under Medicare Part A, including the surgery, hospital care, and certain recovery services. If the procedure is outpatient, often done the same day, Medicare Part B covers doctor visits, the surgery itself, and rehabilitation services like physical therapy.

This distinction ensures you understand which services are covered under each part of Medicare based on your surgery setting.

Overview of Medicare

Medicare is a federal health insurance program primarily for individuals aged 65 and older, but it also serves younger people with certain disabilities or health conditions. It’s divided into four parts:

• Part A (Hospital Insurance): Covers inpatient hospital stays, surgery costs, care in skilled nursing facilities, hospice care, and some home healthcare services.
• Part B (Medical Insurance): Covers outpatient care, doctor visits, medical supplies, preventive services, and certain surgeries performed without an overnight hospital stay.
• Part C (Medicare Advantage): Offered by private insurers, Medicare Advantage plans combine Parts A and B and often include extra benefits like vision, dental, wellness programs, and enhanced rehabilitation services.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications, including drugs needed for pain management and recovery after knee surgery.

Understanding how these parts work together can help you better manage your healthcare costs and choose the best coverage option for your needs.

What to Expect After Knee Replacement Surgery 

Recovery from knee replacement surgery involves rehabilitation to regain strength and mobility. Medicare Part B covers outpatient physical therapy if prescribed by your doctor. If your recovery requires additional inpatient rehabilitation or nursing care, Medicare Part A may cover that as well. Be sure to discuss your recovery plan with your healthcare provider to understand what costs might be covered.

Medications and Part D

After knee replacement surgery, managing pain and supporting recovery often require prescription medications. Medicare Part D helps cover the cost of these drugs, easing some of the financial burden during your healing process.

It’s important to review your Part D plan carefully to make sure it covers the medications you may need after surgery, such as pain relievers, blood thinners, or antibiotics. Coverage can vary between plans, so checking the formulary (the plan’s list of covered drugs) ahead of time can help you avoid unexpected costs.

If you’re enrolled in a Medicare Advantage plan that includes drug coverage, be sure to ask whether your post-surgery prescriptions are included as well.

What to Know About Pre-Surgery Requirements 

Before undergoing knee replacement surgery, your doctor may need to conduct specific evaluations to ensure you’re a good candidate for the procedure. Medicare generally covers necessary pre-surgery tests and evaluations, such as X-rays or lab tests, when deemed medically necessary. Make sure these procedures are documented properly to avoid unexpected out-of-pocket costs.

Steps to Secure Coverage

Following these steps can streamline the process and help manage costs effectively:

1. Review Your Medicare Plan

Start by reviewing the details of your current Medicare coverage. Check what’s included under Parts A and B, paying special attention to how hospital stays, outpatient surgery, and rehabilitation services are handled. Understanding these details upfront can help you plan for any potential out-of-pocket expenses.

2. Consult With Healthcare Providers

Discuss your knee surgery with your doctor and care team. This is the time to ask your question, “Does Medicare covers knee replacement costs?” Confirm that all providers involved accept Medicare and ensure the procedure is documented as medically necessary. This will help you determine if Medicare covers knee replacement costs, as it’s a key requirement for coverage.

3. Check Medicare Advantage Options

If you’re enrolled in a Medicare Advantage (Part C) plan, contact your provider to confirm coverage for knee replacement surgery. Ask about any additional benefits, like reduced copayments or extended physical therapy services, which could help with recovery costs.

4. Review Your Part D Prescription Drug Coverage

After surgery, prescription medications will likely be part of your recovery plan. Review your Medicare Part D plan to make sure it covers the medications you’ll need, such as pain relievers and blood thinners. It’s also smart to check for any recent formulary changes that could affect your coverage.

5. Get Expert Help if Needed

If you’re unsure about your options, a licensed Medicare insurance agent can offer personalized advice. They can walk you through available plans, help you understand your benefits, and recommend strategies to minimize out-of-pocket costs.

FAQs

What is the cost of a total knee replacement if you are on Medicare?

The cost of knee replacement varies depending on whether it’s inpatient or outpatient. While Medicare typically covers most of the surgery, there are still costs such as deductibles, coinsurance, or copayments. Costs can range from a few hundred to several thousand dollars, depending on your specific situation.

At what age does Medicare stop paying for a knee replacement?

Medicare continues to cover knee replacement surgery for eligible individuals as long as the surgery is deemed medically necessary, regardless of age. Coverage is available to those 65 and older, or under 65 with certain disabilities.

How do you get approved for a knee replacement?

To qualify for knee replacement under Medicare, your doctor must document that the procedure is medically necessary, typically showing that your condition significantly impairs daily activities and that conservative treatments like physical therapy or medication haven’t been effective.

Book a Consultation for Personalized Medicare Guidance

Asking “Does Medicare cover a knee replacement?” Get clear, personalized answers by scheduling a consultation with our team. We’ll walk you through how Medicare coverage works for knee replacements and help you understand your options for reducing out-of-pocket costs.

During your consultation, you’ll receive tailored advice based on your specific situation to make confident, informed healthcare decisions.

Reach out today to book your appointment.