Does Original Medicare Help Pay for a Hip Replacement?

Medicare Benefits Solutions
Aug 9, 2022

Medicare helps cover the cost of hip replacement surgery, AKA total hip arthroplasty, and other surgical services when deemed medically necessary. The exact amount of coverage depends on a number of factors such as the cost of the surgery and your specific plan benefits.

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Is Hip Replacement Considered Medically Necessary?

If you feel chronic pain in your hip when you walk, stand, sit, bend, or climb stairs, it’s a good idea to schedule an appointment with your doctor. If you have hip pain or stiffness even when you are still, make sure you share that information during the exam.  

During this type of surgery, the damaged area of your hip is replaced with an artificial joint that may be made out of ceramic, metal, or hard plastic. Hip replacement surgery includes:

  • hip resurfacing
  • partial hip arthroscopy
  • total hip arthroscopy

The cause of your hip pain may be age-related or due to underlying conditions like arthritis. In older adults, the source of hip pain not caused by an injury is often rheumatoid arthritis (inflammatory joint disease) or osteoarthritis (joint breakdown), but there are many other causes your doctor will consider.

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Why You Might Need a Hip Replacement

According to the Centers for Medicare & Medicaid Services (CMS) database, total hip arthroplasty approval is based on stringent criteria. The requirements include:

  • Advanced joint disease supported by imaging studies
  • Pain and functional disability resulting from injury caused by trauma or arthritis of the joint 
  • A history of unsuccessful attempts at conservative therapy. 

If your pain reaches the stage where you are unable to rest, perform your day-to-day routine or stay active, your doctor may begin treatment with medication, walking aids like a cane or walker, physical therapy, or injections. 

Your personal medical history and diagnostic exams will be taken into account when your doctor makes recommendations for your care. If none of these treatments are effective in reducing your pain or symptoms, you may be referred to an orthopedic surgeon to evaluate your eligibility for hip replacement surgery.

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How Much Does Medicare Cover for Hip Replacement?

Discuss with your surgeon where the procedure will be performed. The parts of Medicare covering the surgery depend on whether you are an inpatient or an outpatient. 

Part A covers inpatient care in a hospital and skilled nursing facility (SNF). Part B covers outpatient medical services, outpatient surgeries and necessary supplies. A second surgical opinion is also a Part B benefit.  

Part B covers your physician’s services whether you are an inpatient or outpatient. You are responsible for the Part B deductible and 20% coinsurance applies. 

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Does Medicare Part A Pay for Hip Replacement?

The following Medicare benefits apply to hip replacement surgery hospital inpatients:

  • Semi-private room
  • Meals
  • General nursing
  • Medication
  • Other hospital services and supplies

Part A patient cost-sharing includes a deductible for each benefit period. A benefit period is a term that Original Medicare uses to measure hospital and Skilled Nursing Facility usage. The period begins the day of admittance and ends after you go 60 consecutive days without using the benefit. If you have a Medicare Supplement (Medigap) plan, check your policy to see if the deductible is covered. 

If you need to stay in the hospital for over 60 days, you have to pay a copayment for each day. After 150 days, you pay for all hospital charges. If you’ve purchased a Medigap plan, you may get coverage for Part A copayments and hospital charges up to an additional 365 days after Medicare benefits have run out.

The Medicare procedure-price-lookup tool gives you a quick snapshot of patient responsibility after Medicare pays the facility and doctor. Using this tool, the estimated national averages for total hip arthroplasty in 2022 are about $2,000 for ambulatory surgical centers and about $1,800 for hospital outpatient departments. 

Once your doctor orders the surgery, you can discuss the actual projected charges with the facility’s billing department.  

Does Medicare Cover Rehab After Hip Surgery?

Some patients require inpatient rehabilitation after surgery where they can get physical therapy to regain range of motion and muscle strength. 

Medicare Part A covers a semi-private room, meals, skilled nursing services and therapy in a Skilled Nursing Facility (SNF) if you meet the following requirements:

  • Your ability to improve or maintain your condition requires skilled nursing care or therapy services.
  • Your doctor certifies that you require daily skilled care that you can only get as an SNF inpatient.
  • You must have been a hospital inpatient for three days, at least, for a related condition.

If approved, the maximum benefit is 100 days for each benefit period. You do not have to pay a deductible or any charges for the first 20 days. A coinsurance is due for days 21 through 100. Some Medigap plans cover SNF coinsurance.  

Does Medicare Hip Replacement Include In-home Care?

If you are homebound and your doctor certifies that you need home health services, you may be eligible for Medicare coverage under Part A and/or Part B. Benefits include medically necessary physical therapy, occupational therapy and home health aide services, depending on the level of care you need. You may be able to rent or purchase durable medical equipment, such as a wheelchair, walker and hospital bed

Medicare does not cover long-term care, so home health services are closely monitored and approved on a short-term basis. The services must be delivered by a Medicare-certified home health agency, and the agency will closely monitor and document your progress. As you recover, the agency transitions you out of the program. 

Does Medicare Advantage Cover Hip or Knee Replacement?

Medicare Advantage (MA) covers the benefits provided by Original Medicare and often includes additional benefits. If you have an MA plan, you may have extra coverage that may apply to your hip replacement surgery or post-operative care. Depending on the MA plan you have enrolled in, you may have to use doctors and hospitals within the plan’s network. 

Hip Replacement Pros and Cons

As with all surgeries, there are risks associated with hip replacement. Discuss the benefits and risk factors with your doctor. 

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