Yes, Medicare does cover knee replacement surgery, given the procedure qualifies as medically necessary. Medicare categorizes medical necessity as any health care services or items required to diagnose or treat a disease, injury, or condition that meet accepted standards of medicine. For Medicare to contribute to surgery costs, your doctor must diagnose your condition and declare knee replacement as your only viable treatment method.
If you qualify, Medicare Part A covers most of your inpatient hospital stay. Part B would pay for some of your doctor’s services and most other affiliated medical costs. Even with Medicare coverage, patients must pay their Part A and B deductibles and all relative coinsurance and copayments out-of-pocket.
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What Is a Knee Replacement?
A knee replacement is when a surgeon removes and either fully or partially replaces the worn ends of your knee joint with plastic or metal parts, depending on the extent of joint damage. If successful, joint replacement should relieve pain, improve mobility, and increase your quality of life.
This surgery is very common. Almost 800,000 knee replacement surgeries are done every year in the U.S. Many of those patients were Medicare beneficiaries over 65 with arthritis or degenerative joint disease.
How Do Medicare Knee Replacements Work?
You must first meet certain eligibility requirements to qualify for knee replacement surgery. Then, as long as a doctor determines knee replacement surgery as medically necessary, Original Medicare Part A and B will each kick in to pay for particular aspects of the operation and your recovery.
Eligibility Requirements for Knee Replacements
For knee replacement surgeries to qualify as medically necessary under Medicare, patients’ conditions must meet at least three of the following criteria:
- Advanced joint disease or deterioration as indicated by an MRI
- Documented history of unsuccessful therapeutic treatment over a minimum of three months
- Extreme pain due to arthritis or trauma to the knee that inhibits you from fulfilling basic activities of daily living such as dressing, bathing, or going to the bathroom
- Distinct structural abnormalities such as a proximal tibia fracture or osteonecrosis of the knee
- Failed previous joint replacement requiring a second operation, indicated by infection, stiffness, inability to bear weight, or mechanical failure of the replacement knee’s components
Which Medicare Part Covers Knee Replacements?
Knee replacement surgeries involve multiple medical services that register in separate Medicare categories. Medicare Part A, also known as hospital insurance, covers inpatient stays at eligible care centers such as general hospitals and skilled nursing facilities. If you need a knee replacement, Part A will pay for time spent in the hospital before and after surgery.
Medicare Part B, also known as medical insurance, pays the cost of medical items and doctors’ services necessary for an inpatient or outpatient procedure. For knee replacement surgery, these expenses could include a percentage of your surgeons’ fees, post-op doctor visits, anesthesia, X-rays, physical therapy, and durable medical equipment such as wheelchairs and braces.
What Type Of Knee Replacements Are Covered By Medicare?
Depending on your condition, Medicare will cover the following medically necessary procedures:
- Total Knee Replacement: Replacement of your whole knee with an artificial prosthetic joint
- Partial Knee Replacement: Removal and replacement of bone surfaces from only one part of the knee
- Knee Cap Replacement: Also known as a patellofemoral replacement, this procedure removes only the front of the knee through a smaller incision
- Complex or Revision Knee Replacement: A follow-up procedure to address a previously failed knee replacement surgery
- Bilateral Knee Replacement: Replacement of both knees during the same surgical procedure
Some of these services require more invasive surgery, longer recovery time, and extended physical therapy, directly correlating to the amount you’ll pay out-of-pocket alongside your Medicare coverage.
What Treatment Is Not Covered?
Medicare will only cover knee replacements deemed medically necessary by a doctor and will not pay for any part of elective or experimental surgery. Furthermore, Medicare Part A will only fully pay for an inpatient hospital stay up to 60 days before charging additional out-of-pocket coinsurance.
Out-of-pocket coinsurance and copays for doctor’s services, prescriptions, and durable medical equipment always fall on the patient, regardless of their Medicare coverage.
How Does Medicare Advantage Cover Knee Replacements?
According to Medicare bylaws, Medicare Advantage must offer all the same coverage benefits as Original Medicare. Therefore, anyone eligible for knee replacement surgery under Original Medicare can get the same procedure with a Medicare Advantage policy. Medicare Advantage plans occasionally offer additional covered benefits for knee surgery, such as:
- Installation of bathroom handlebars in a patient’s home
- Prescription pain pills
- Meal delivery allowance
Because private companies oversee these policies, plan benefits and patient cost-sharing responsibilities vary widely from plan to plan. Medicare Advantage plans also have an out-of-pocket spending limit, meaning that your insurance provider must take over the total cost of care after you reach a set out-of-pocket spending cap each year.
Out-of-Pocket Costs Associated With Medicare Knee Replacements
The average national cost of knee surgery is around $29,300. While Medicare covers much of the expense, patients should still prepare for the following out-of-pocket costs for an inpatient procedure:
Expense | Price |
|---|---|
$1,600 | |
$226 | |
Prescriptions | ~$100. If you have drug coverage, you will still need to pay a small copay with every prescription refill (e.g., $15). |
DME | |
Coinsurance (Part B) | ~$4000. Part B asks for 20% coinsurance for all covered medical services. |
Copays | ~$100. Cumulative small fees (e.g., $25 each) due with each follow-up appointment. |
Total | ~$6,026 |
Other than the firm policy deductibles, these numbers are estimates. Actual out-of-pocket fees will vary widely depending on the nature of your surgery and numerous other factors. Individuals can purchase separate Medicare Supplement plans, or Medigap, to help absorb some of these expenses.
What If I Cannot Afford the Costs?
If you do not have Medicare or can’t afford the affiliated out-of-pocket costs, explore the following options:
- Medicaid: This is state-administered health insurance for low-income Americans, typically at little to no charge.
- Extra Help/Low-Income Subsidy (LIS): This is agovernment program that helps reduce Medicare prescription drug costs for low-income members.
- Medicare Savings Programs: MSPs help low-income Medicare beneficiaries pay deductibles, copays, coinsurances, and premiums.
- Payment plans: Most hospitals allow patients to finance their out-of-pocket expenses using a medical credit card or payment plan.
- Social Security Disability Insurance (SSDI): This social insurance program benefits disabled workers who have paid Social Security taxes on their earnings.
How to Gain Eligibility for a Knee Replacement With Medicare
Eligible seniors must still abide by a step-by-step bureaucratic process within the healthcare system to ensure proper coverage for knee replacement surgery.
1. Diagnosis
Though doctors commonly recommend knee replacement surgery for debilitating pain caused by arthritis, they will still need to investigate the area before approving surgery. Your provider will check your knee’s range of motion, stability, and strength and likely have X-rays taken to reveal the full extent of the damage. Depending on the results — often in conjunction with a previous diagnosis — they will identify the source of your pain and determine whether it justifies surgery. Occasionally, your doctor may refer you to an orthopedic specialist for a second opinion.
2. Documentation
Once diagnosed, ensure you receive a certified document from your physician explicitly recommending knee replacement surgery. Your doctor’s note should clearly support the diagnostic criteria required for such a procedure and declare that the surgery would not exceed medical need and that no alternative care options would adequately treat your condition. Your medical provider should also update your medical record to include recent X-rays and a detailed history of unsuccessful physical therapy and medications you’ve tried but did not solve the issue.
3. Pre-surgery Requirements
Once your documentation and medical record detail your need for surgery, you must pick out an in-network hospital and speak with a Medicare-approved surgeon who will walk you through the upcoming procedure. The medical team will inquire about pre-existing health conditions such as heart problems or drug allergies that would complicate surgery. Your doctors may also recommend you stop taking certain medications or eating specific foods before the surgery and help you establish a recovery plan.
4. Approval
Your doctor or specialist will file your knee replacement surgery claim directly with Medicare. If approved, you should receive a Medicare Summary Notice (MSN) in the mail. Your MSN will lay out the total cost of the bill for surgery, how much Medicare will pay, and the maximum amount you will owe your medical providers out of pocket.
What if Medicare Declines To Cover the Procedure?
If Medicare declines to cover your knee replacement surgery, you hold the right to an appeal. Start by filling out a Redetermination Request Form and send it to the company that handles claims for Medicare. This company’s address and appeal deadline date should appear on your Medicare Summary Notice.
Appeals typically get decided within 60 days. If Medicare turns around and decides to pay for your surgery, they will list their coverage amounts for necessary surgical items and services on your next MSN. Some experts recommend following an appeals template to ensure you cover all your bases leading up to arbitration.
Alternatives to Knee Replacement Surgery
If Medicare denies knee replacement surgery or your doctor doesn’t view the procedure as medically necessary, you can explore other alternative routes toward pain relief.
Physical Therapy
Sometimes, a focused course of physical therapy can significantly help alleviate joint pain. Trained experts can guide patients through exercises designed to strengthen muscles in the leg surrounding the knees, reinforcing support to reduce pain. Luckily, Medicare Part B covers 80% of all medically necessary outpatient physical therapy services once patients meet their Part B deductible. Physical therapy can take several weeks or even longer, depending on the nature of your condition.
Weight Loss
Extra weight on your body puts pressure on your knees and strains the joints, worsening your pain and making it harder to exercise and strengthen neighboring muscles. Medicare Part B will cover weight loss counseling for members with notably high BMIs, often exempting these individuals from out-of-pocket expenses by classifying counseling as preventative care. To qualify for Medicare coverage, a primary care provider must conduct your sessions in an eligible primary care setting for no longer than one year. In some cases, patients with BMIs above 35 may even qualify for weight loss surgery.
Medications and Injections
Medicare Part B will cover medically necessary knee injections every six weeks for patients who have undergone X-rays indicating localized osteoarthritis. Furthermore, if you have the Medicare drug plan (Part D), you should receive coverage for most prescription pain medications. Because private companies offer Medicare Part D, eligible prescriptions and associated out-of-pocket costs will vary from plan to plan. Part D typically requires members to meet a deductible before providing coverage and asks for a copay or coinsurance with every prescription refill.
Braces and Sleeves
Wearing a knee brace or sleeve can help reduce pain by shifting weight off the vulnerable section of your knee, improving your ability to get around comfortably for extended periods. Knee braces qualify for durable medical equipment coverage under Medicare Part B. Therefore, Medicare will pay 80% of any medically necessary brace or sleeve ordered by a Medicare-enrolled doctor. You can wear a knee brace or sleeve as long as needed if it helps alleviate pain.
Alternative Therapies
If more conventional care methods fall flat, you can research alternative treatments such as acupuncture or directed massage therapy to relieve joint pain. Unfortunately, Medicare does not cover massage therapy and will only cover a limited amount of acupuncture prescribed explicitly for lower back pain. Patients would therefore have to pay for these alternative care methods 100% out of pocket. Costs of professional massages and acupuncture sessions typically start around $60 on the low side but can range much higher depending on the service and provider.
Putting It All Together
If your chronic knee pain actively inhibits your ability to live a comfortable life, talk to a Medicare agent about how Original Medicare will cover medically necessary knee replacement surgery and how you might begin the proceedings. If you do not qualify for a Medicare-approved knee replacement surgery, explore the many Medicare-eligible alternative treatments to address joint pain, including weight loss counseling, physical therapy, prescription injections, and more.