Hip replacement procedures are quite common in the United States. In 2020, surgeons performed 498,000 hip replacement procedures, and medical professionals estimate that by 2025 that number will increase to over 600,000 per year.
Your physician might suggest that you consider getting a hip replacement if you are in pain or have problems with mobility and flexibility. Many people who are living with osteoarthritis, rheumatoid arthritis, osteonecrosis, chondrosarcoma, or who have had a hip injury or fracture get relief after having hip replacement surgery.
Hip replacement surgery involves replacing the damaged portions of the hip joint with a prosthetic implant typically made of metal, ceramic, and hard plastic materials. You may have a total replacement or a partial replacement depending on your condition.
Do Medicare benefits cover hip replacement?
Medicare generally covers hip replacement surgeries. To be eligible for this coverage, your health care provider (who accepts Medicare assignment) must certify that the procedure is medically necessary.
Depending on where you have your hip replacement surgery done, what type of care you need afterward, and what medication you need for recovery, your coverage may fall under the different parts of Medicare. Here’s a breakdown of how Medicare coverage works for hip replacement surgery:
For beneficiaries who have Original Medicare Parts A and B:
Original Medicare Part A hospital insurance covers hip replacement surgery when your doctor gives an official order stating you need inpatient hospital care to treat your injury or illness. Also, you must be admitted to a hospital that accepts Medicare assignment to get Medicare Part A coverage.
Together with your hip replacement procedure and prosthesis, Medicare Part A covers the following services while you’re an inpatient:
- Your semi-private room
- Nursing care
- Drugs associated with your treatment while you are in the hospital
- Skilled nursing care for the first 100 days after your procedure, including physical therapy
As a beneficiary of Original Medicare Part A, you are responsible for paying the deductible for the current benefit period. In 2022, this amount is $1,556.00. Part A doesn’t charge coinsurance for days 1-60. However, days 61-90 carry a coinsurance of $389.00 per day (2022), and days 91 and beyond carry a coinsurance of $778.00 per lifetime reserve day. If your lifetime reserve days end, you must pay 100 percent of all costs for each day afterward.
Original Medicare Part B medical insurancecovers your hip replacement surgery if you have it done in an outpatient surgical facility. To be eligible for this coverage, your physician must certify that the procedure is medically necessary, he must accept Medicare assignment, and the surgical facility must also accept Medicare assignment.
Original Medicare Part B helps you pay for your physician’s fees for visits before and after surgery, the surgical procedure, and post-op physical therapy. Part B also covers a portion of the cost to purchase or rent durable medical equipment, like a cane or walker, that is certified as being medically necessary for your treatment, and that is provided by a supplier that accepts Medicare assignment.
Original Medicare Part B covers 80 percent of the final approved cost for the above-mentioned services and supplies related to your hip replacement surgery. You are responsible for the remaining 20 percent of the cost after meeting your annual Part B deductible.
For beneficiaries who have a Medicare Advantage (Part C) plan
Your Part C plan provider is obligated to cover all the benefits that you would get if you had Original Medicare Parts A and B. If you meet Medicare’s eligibility requirements, your Medicare Advantage plan covers your hip replacement. However, your plan may also require that you use physicians, surgeons, hospitals, and/or medical facilities that are in your plan’s preferred network of providers.
Prescription drug coverage
After your hip replacement procedure, you may need prescription drugs for pain management or blood thinners, for example. If you don’t have a Medicare Part D plan or prescription drug coverage bundled with your Medicare Advantage plan, you may need to pay for these prescription drugs out-of-pocket. Otherwise, your Part D plan should cover its portion of the cost. Check with your plan’s formulary to make sure your specific medications are covered.