Medicare covers hip replacement surgery when it is medically necessary. To be considered medically necessary, your health records must document the pain and limitations caused by your condition. It must also show that other treatment options like physical therapy and prescription medications did not resolve the problem.
Understanding how Medicare covers hip replacements, eligibility requirements, and average out-of-pocket costs can help you prepare for surgery. Here’s what you need to know.
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What Is a Hip Replacement?
A hip replacement, also known as hip arthroplasty, begins with surgically removing a damaged or diseased hip joint. The surgeon then replaces the natural joint with an artificial metal, plastic, or ceramic joint. Hip replacement surgery helps relieve pain, enhance mobility, and improve the overall function of the hip, making daily activities more manageable.
Common conditions that require hip replacement include:
- Osteoarthritis
- Rheumatoid arthritis
- Hip fractures
Other conditions that cause severe pain and/or limited mobility in the hip joint may also lead to surgery.
Hip replacements are common. Surgeons perform more than 450,000 per year in the United States alone. Since the average age for a hip replacement is between 66 and 68, many patients rely on Medicare to cover surgery expenses.
How Medicare Covers Hip Replacement Surgery
Original Medicare consists of two parts, and both parts can cover hip replacement surgery:
- Part A: Medicare Part A covers hip replacements performed in an inpatient facility, such as a hospital. After you pay your deductible ($1,632 per benefit period in 2024), Part A covers the cost of the surgery and some associated costs, including a semi-private hospital room, nursing care, and drugs administered while you are in the hospital.
- Part B: Medicare Part B typically covers 80% of the approved amount for hip replacements performed in an outpatient facility. After you pay your annual deductible ($240 in 2024), Part B covers doctor’s services, post-surgical physical and occupational therapy, and necessary medical equipment.
Eligibility Criteria
Medicare covers medically necessary hip surgeries. Typically, you must meet the following criteria for coverage:
- You have a documented condition like osteoarthritis, rheumatoid arthritis, or a hip injury that significantly impairs mobility or causes chronic pain.
- Your doctor can show that less invasive treatments, such as medication or physical therapy, have not provided relief.
- Your doctor and surgeon confirm that hip replacement surgery is the recommended option to improve your quality of life.
Medigap and Hip Replacements
Medigap is a supplemental insurance policy offered by private insurance companies. These types of plans require a separate premium payment, but can help beneficiaries save money in the long term by reducing Medicare’s out-of-pocket expenses, such as deductibles, copayments, and coinsurance. Some plans may also cover charges exceeding the Medicare-approved amount.
For example, you might enroll in Medigap Plan D and get your hip replacement surgery done in a hospital. Your Medigap plan would cover your Part A deductible and your hospital copay costs for your surgery. Specific benefits depend on which Medigap plan you enroll in.
Medicare Part D and Hip Replacements
Hip replacement is a major surgery with an average recovery time of around 6 weeks. It’s common for patients to need prescription medications after the procedure to manage pain and aid recovery. However, Original Medicare typically does not cover this cost.
Medicare Part D is an optional coverage that helps pay for prescription drugs. Most Part D plans cover medications associated with hip replacement surgery, such as antibiotics, blood thinners, and pain-management medications. Part D premiums, deductibles, copayments, and coinsurance vary based on the plan selected.
Medicare Advantage and Hip Replacements
Medicare Advantage Plans, also known as Medicare Part C, are an alternative to Original Medicare. Offered by private insurance companies approved by Medicare, Part C Plans cover everything Original Medicare does, and many plans offer additional benefits. For example, Medicare Advantage Plans often bundle Part D prescription drug coverage for a single, comprehensive plan and extended benefits like vision, dental, and hearing coverage.
This means Medicare Advantage Plans cover hip replacements and may also cover additional costs associated with the surgery that Original Medicare does not. For example, a Medicare Advantage Plan may cover prescription medications to help with recovery and extra post-surgical rehabilitation. To understand your coverage, consult your Medicare Advantage Plan documents or work with a licensed agent or broker to learn more about plans available in your area.
How Much Does a Hip Replacement Cost With Medicare?
Part A | Part B | Medicare Advantage | |
|---|---|---|---|
Premium | $0 for most people | $174.70 per month for most people | Varies; some plans offer $0 premiums |
Deductible | $1,632 per inpatient hospital benefit period | $240 per year | Varies depending on plan |
Copay | $0 for first 60 days of hospitalization | None | Varies depending on plan |
Coinsurance | None | 20% of the Medicare-approved amount | Varies depending on plan |
Out-of-pocket Maximum | None | None | $8,850 or lower for 2024 |
Prescription Coverage | None | None | Many plans bundle Part D prescription coverage, but check with your insurer or a trusted agent to be sure |
Medigap Coverage | Compatible | Compatible | Not compatible |
The cost of a hip replacement under Original Medicare depends on where you have the surgery. For example, a total hip replacement performed at an ambulatory surgical center breaks down to the following average costs:
- Total procedure: $10,502
- Medicare payment: $8,401
- Beneficary’s out-of-pocket cost: $2,101
The average procedure cost includes facility and doctor’s fees. However, your out-of-pocket costs may be higher if you need additional doctors or other services.
When the surgery is performed at a hospital, the average costs are:
- Total procedure: $13,803
- Medicare payment: $11,918
- Beneficiary’s out-of-pocket cost: $1,885
Beneficiaries who undergo inpatient hip replacement surgeries have no copayment for the first 60 days of the hospital stay after they meet the Part A deductible. After 60 days, copay rates apply.
After the Surgery: Recovery From Hip Replacement With Medicare
After hip replacement surgery, patients typically need physical therapy to regain mobility and occupational therapy to help with daily tasks like showering.
If medically necessary, Medicare Part A covers rehabilitation therapy and skilled nursing care. Medicare Part B covers follow-up visits with a doctor and physical and occupational therapy. Part B also covers durable medical equipment, such as crutches or walkers.
Medicare Part D or Medicare Advantage Plans may cover prescription medications that can help with recovery and pain management after hip surgery.
Putting It All Together
Original Medicare covers hip replacement surgery when it is medically necessary. A Medigap policy can make the surgery more affordable by reducing out-of-pocket expenses like deductibles, copayments, and coinsurance.
While Original Medicare does not cover prescription drugs, Medicare Part D can help cover the cost of prescription medications associated with hip replacement surgery. Many Medicare Advantage Plans also include prescription drug coverage and may offer additional coverage beyond Original Medicare, further reducing out-of-pocket costs.