Does Medicare Cover Knee Replacement Surgery Costs?

Medicare Benefits

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If your doctor determines you need total knee replacement Medicare will cover some of the costs. Medicare covers medically necessary inpatient surgery under Part A and outpatient surgery under Part B. 

If hospital admittance is required, you may expect one or two days in the hospital for a partial knee replacement or three to four days for a total joint replacement. Let’s take a closer look at how Part A and Part B may help cover the costs of your knee replacement. 

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Part A Total Knee Replacement Coverage

Medicare Part A, hospital insurance, includes a semi-private room, all meals, general nursing services, medical supplies and medication.

Part A coverage is usually premium-free based on taxes you’ve paid while working. Medicare Part A requires a deductible but no coinsurance for the first 60 days of each benefit period. There is no cap on the number of benefit periods you can have. 

So, if you have had multiple stays in a skilled nursing facility or hospital, you may be responsible for more than one deductible in a year. Each benefit period starts on the day of admission and ends after 60 consecutive days of no inpatient care. Following the 60-day lapse, a new admittance initiates the next benefit period. 

If you’ve purchased a Medicare Supplement policy (Medigap), your coverage includes Part A coinsurance, applicable on day 61 of admission. Medicare Supplement plans may also cover hospital costs up to one year after Original Medicare benefits run out. Some Medigap policies cover all or part of the Part A deductible. 

Part B Knee Surgery Coverage

Medicare Part B, medical insurance, covers your doctor’s services. Part B also includes medically necessary outpatient surgery, supplies and services. It may help cover durable medical equipment (DME) you may need as you recover from your surgery at home. 

Your share of the cost for covered services is 20% of the Medicare-approved amount.  The annual Part B deductible applies. Hospital outpatient facilities may charge you a copayment, usually not more than the Part A inpatient hospital deductible.

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Medicare Part D Coverage

Part D is Medicare prescription drug coverage. You may enroll in a stand-alone Part D plan if you have Original Medicare or choose to sign up for a Medicare Advantage plan that includes prescription drug coverage (MA-PD). If you are prescribed medications after your knee replacement surgery, check your plan’s formulary for specific coverage information.

Does Medicare Advantage Cover Knee Replacement?

As with Original Medicare, your knee replacement surgery must be medically necessary to qualify for benefits under a Medicare Advantage (MA) plan. MA plans are required to include the same Part A and Part B benefits as Original Medicare, but most plans include additional coverage. 

Your cost-sharing and provider options may be different. Your Medicare Advantage policy may not stipulate a three-day minimum hospital stay before rehabilitation but can require SNF copayments from day 1.

Read your plan’s Evidence of Coverage for benefit details. To keep your out-of-pocket cost to a minimum, you may have to choose doctors and facilities in the plan’s network. Reach out directly to your plan if you have specific questions regarding coverage.

TIP: Discover the top 7 reasons why you might want to switch your Medicare Advantage plan.

Does Medicare Cover Inpatient Rehab After Knee Surgery?

Temporary care in a rehabilitation center or skilled nursing facility (SNF) is a Part A benefit. If your doctor recommends it, Part A will cover a semi-private room, three meals, nursing and therapy. Your doctor must certify that inpatient rehab care is medically necessary. Medicare covers a maximum of 100 days with coinsurance starting on day 21.

If you have outpatient surgery, emergency and observation services may require an overnight stay. However, you are not considered an inpatient unless the hospital formally admits you. This is important because Medicare requires that at least three days as a hospital inpatient precede rehab for a related illness or injury. If you are under observation for over 24 hours but have outpatient status, the hospital has to give you a Medicare Outpatient Observation Notice (MOON). 

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What Qualifies a Person for Total Knee Replacement?

Before considering major surgery, you should explore all possible options.

Knee replacement alternatives include:

• Knee gel injections
• Physical therapy
• Walkers and other durable medical equipment
• Radiofrequency ablation to control knee pain
• Cortisone shots to temporarily minimize pain and inflammation

Once you’ve exhausted all alternative medicine and holistic doctor options, it may be time to schedule a surgical consultation.

If you have total knee arthroplasty for advanced joint diseases, Medicare requires that your doctor provide the following documentation:

• Imaging (X-rays, MRIs, or CT scans) that supports evidence of arthritis of the knee, demonstrating specific problems like joint space narrowing or bone-on-bone articulation
• Description of pain or inability to function, such as pain that disrupts activities of daily living
• History of unsuccessful efforts to manage the condition conservatively with non-surgical approaches, such as physical therapy and non-steroid anti-inflammatory drugs (NSAIDs)
• Risks and benefits of surgery applicable to patients with multiple chronic conditions or diseases 

Why Would You Need a Knee Replacement?

Knee pain can be caused by injuries, aging, or repeated stress on the joints. If you’ve been experiencing chronic discomfort, or if it’s severe enough to affect your quality of life, it may be time to speak with a physician. 

The Cleveland Clinic identifies three reasons for an orthopedic surgeon to recommend arthroplasty:

1. Joint pain not improved with nonsurgical approaches like physical therapy, medication, braces, injections, walking aids and rest
2. Joint stiffness and mobility are limited enough to make daily activities challenging or prohibitive
3. Inflammation unresponsive to medication or lifestyle modifications

These issues may be caused by arthritis, fractures, joint abnormalities, or avascular necrosis. 

Treatment can include a wide range of medications and physical therapy.  If you have bad knees and non-surgical treatments have not improved your condition, your doctor may recommend knee replacement surgery. Knee replacement is a type of arthroplasty, the surgical replacement of a joint. 

Knee and hip replacements are the most common types of arthroplasty. Medicare coverage applies if your doctor deems the procedure medically necessary. Other restrictions may apply depending on the plan you’re enrolled in. Factors impacting the cost include the extent of knee damage and whether you need inpatient or outpatient surgery.

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