If your knee pain seems to be getting worse lately and you’ve exhausted other options, you might have knee replacement surgery at the back of your mind. It’s probably not something to look forward to, but if having it makes your quality of life better, perhaps it’s a good option.
Your doctor may suggest that you try losing weight, getting more exercise, and taking medication for pain relief. But if you can’t sleep at night due to pain, can’t walk up the stairs, stand up for periods of time, or walk comfortably, it might be time for knee replacement surgery.
Surgeons perform close to 800,000 knee replacement (also known as knee arthroplasty) procedures every year in the United States. While this is a common procedure, it’s still major surgery.
Depending on the degree of damage to the knee joint, doctors can perform either partial or total replacements. During surgery, the damaged surfaces are replaced with metal and plastic to help the knee regain smooth motion.
Even though the recovery process can be painful and long with a lot of physical rehabilitation, patients say that knee replacement surgery gets them back to a pain-free and more mobile lifestyle.
Does Medicare cover knee replacement?
If your Medicare-affiliated physician certifies that a knee replacement is medically necessary to treat a condition you have, your surgery is covered by Medicare. Here’s a look at which part of Medicare covers the surgery:
For beneficiaries with Original Medicare Parts A and B:
If you have the procedure done in a hospital, then your surgery is covered by Original Medicare Part A (hospital insurance) if you meet both of the following conditions:
- You are admitted to the hospital as an inpatient because your physician has officially ordered it. Your admission must be for care focused on treating your illness or injury.
- The hospital accepts Medicare assignment.
As an inpatient, Medicare covers the following services along with your surgical procedure:
- A semi-private room and your meals
- General nursing care
- Drugs while an inpatient
- Other miscellaneous hospital services and supplies related to your inpatient treatment
If you need skilled nursing care during your recovery and can’t go home, Original Medicare Part A also covers skilled nursing care in a facility on a short-term basis when all the following conditions apply:
- You have Medicare Part A coverage, and you have days remaining on the current benefit period.
- You have an inpatient hospital stay that qualifies you for a skilled nursing facility stay.
- Your physician declares your need for daily skilled nursing care that can only be provided at a medical facility.
- The skilled nursing facility accepts Medicare assignment.
- You need nursing care for a hospital-related medical condition (i.e. knee replacement), or for a condition that began while you were getting care in a skilled nursing facility.
Original Medicare Part A covers the cost of your knee replacement surgery after you have paid the Part A deductible for the current benefit period. In 2022, the deductible is $1,556.00. You pay $0 coinsurance for days 1-60, but after day 60, the coinsurance amount increases incrementally.
If you have knee replacement surgery as an outpatient, Original Medicare Part B (medical insurance) covers its share of the final approved cost. To be eligible for this benefit, your physician must accept Medicare assignment and must certify that the procedure is medically necessary. You must also have it done in a hospital or medical facility that accepts Medicare assignment.
Original Medicare Part B pays for 80 percent of the cost, and you are responsible for the remaining 20 percent after paying your annual Part B deductible.
For beneficiaries with Medicare Advantage (Medicare Part C):
If you have a Medicare Advantage plan, your provider must cover all benefits that you’d have with Original Medicare Parts A and B. To be eligible for this coverage, you must meet the same criteria as with Original Medicare. However, depending on the type of plan you have, you may be required to use health care providers, hospitals, medical facilities, and suppliers that are included in the plan’s network of providers.
Many MA plans include additional benefits, so check with your plan directly if you have any specific questions about coverage. Your out-of-pocket costs depend on the coverage you have and what your plan charges for copayments and coinsurance.