When facing a potential knee replacement surgery, many people’s first thoughts might be, “How much will this end up costing me? Will my insurance cover most of it?”
Does Medicare Cover Knee Replacement Surgery Costs?
The short answer is yes, given a few key stipulations. Medicare is a federally subsidized health insurance program for individuals over 65 and certain younger people with disabilities. The three essential Medicare plans to choose from are:
- Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). Part D (the Drug Plan) can be added on separately. Original Medicare covers most, but not all, the costs of any covered procedures. You pay for services as you receive them, usually amounting to around 20% of the actual price of the procedure. If you add a Medigap policy, it will pay part or all of the remaining 20%. Therefore, you will pay even less once the insurance kicks in.
- Medicare Advantage (aka Part C) is a Medicare-approved plan provided through a private company. Every Medicare Advantage Plan comes with its specific out-of-pocket costs, depending on which company you go through. These plans can occasionally offer additional benefits not available through Original Medicare.
- Medigap plans supplement Part B of original Medicare and help share costs that Part B may not, such as copays, coinsurance, and deductibles. Medigap also provides more benefits than Part B does.
Original Medicare covers knee replacement surgery, specifically Part A for an inpatient procedure. Part B would cover any follow-up care and outpatient procedure, should your doctor recommend that route.
The Surgery Must Be Medically Necessary
Having your knee replacement covered by Medicare must be medically necessary. Your doctor will determine whether or not you need the surgery and proceed from there.
Most surgeries covered by Medicare must qualify as a medical necessity. A medical necessity is a procedure that will either save or significantly improve one’s quality of life on a measurable scale, as laid out by a doctor in the appropriate field.
Which Medicare Parts Cover Knee Replacement?
Medicare Part A, B, and C provide different benefits and coverages. Original Medicare comes with Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Advantage (aka Part C) also includes Part A and Part B, but is offered through a private company and has to be approved by Medicare. Part C often comes with additional benefits like vision or dental. Medicare Part D can also be added to either plan for an additional fee and covers drugs prescribed by a doctor.
Part A Coverage
If your knee replacement surgery requires an inpatient procedure, Medicare Part A will cover any hospital costs after your deductible. Part A covers no follow-up visits, care, or related medications.
Part B Coverage
Upon reaching your deductible, Medicare Part B covers 80% of all surgery’s medical costs (inpatient or outpatient). Medical expenses include medically necessary doctor’s visits following the surgery, as well as physical therapy services. It would also kick in to cover 80% of outpatient surgery.
Part C Coverage
Medicare Advantage Plans are required by law to provide all the same coverage as Original Medicare. Coverage for a knee replacement surgery through Medicare Part C would therefore be identical to the coverage you would receive from Part A or Part B through Original Medicare.
Outpatient vs Inpatient Knee Replacement Surgery
Inpatient surgery takes place in a medical facility and requires a stay of recovery at a hospital. In contrast, outpatient surgery allows you to recover in the comfort of your own home.
Most knee replacement surgeries are inpatient procedures. This means the surgery takes place at a hospital, followed by a few additional days of monitoring by medical staff. This option is usually more expensive due to the extra time spent in the hospital.
New surgical techniques have made knee replacement easier to recover from. In light of this phenomenon, outpatient surgery is a more viable option than ever. Following the initial procedure, patients are sent home within 24 hours to recover independently.
How Much Does Knee Replacement Cost?
Knee replacement is major surgery, and various factors can contribute to the overall cost of the procedure. These include:
-Where you live and receive the surgery
-Length of time in the operating room
-Type and amount of anesthesia
–X-rays during and after surgery
-Days spent in the hospital
Without insurance, the average costs of a knee replacement surgery ranged between $30,000 and $112,000. With Medicare, one can expect to pay $383 for outpatient knee replacement procedures and$689 for in-patient treatment.
Alternatives to Knee Replacement Surgery
While not everybody can secure coverage for a knee replacement surgery through Medicare, alternative care methods are still available through the program. Physical therapy, prescription drugs, external medical hardware, and chemical injections are all non-surgical options to help deal with chronic knee pain.
Physical therapy, medical hardware, and several different types of injections would be covered by Medicare Part B. If your plan includes Medicare Part D, prescription pain medication would also be covered.
These medical alternatives may offer adequate relief to joint pain that might otherwise require surgery through proper practice and time.