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Does Medicare Cover Knee Replacement (Arthroplasty)?

September 27, 2023

Does Medicare Cover Knee Replacement (Arthroplasty)?

As we get older, we often struggle with certain aspects of our health. It’s not as easy to move as it used to be, and we have more pain. Some of this is because of the wear and tear our body experiences over the years.

Fortunately, medical procedures are able to help. Treatment options like knee replacement can give us many additional years of better mobility and less pain. But if you rely on Medicare to cover your medical care, you might wonder “Does Medicare cover knee reconstruction?”

This guide will take a look at Medicare coverage for knee replacement (arthroplasty) and answer several common questions. Let’s get started!

Does Medicare Cover Knee Replacement Surgery?

The biggest question most seniors with knee pain have is, “Does Medicare cover arthroplasty?” As with most insurance, Medicare will only cover what’s medically necessary. That means your knee replacement has to be deemed medically needed by a doctor before Medicare will provide coverage.

How your surgery is covered depends on what part of Medicare is used. If you have an inpatient hospital stay, you’ll receive coverage through Medicare Part A. You’ll be responsible for your Part A deductible and then copayments depending on how long the stay is.

If you have outpatient surgery, you’ll be covered under Medicare Part B. After your Part B deductible, you’ll be responsible for 20% of the Medicare-approved cost of the procedure. Learn more about Medicare deductibles, premiums and copays in this guide to Medicare costs.

If you have a Medicare Advantage plan, you’ll be covered under that plan (Medicare Part C). Your private insurance company will have its own deductible and copayment or coinsurance amounts. Be sure to check with your insurer before you schedule the surgery to ensure that coverage will apply as you expect it to.

The most important steps to take before using Medicare for knee replacement are:

  • Make sure a doctor determines the surgery to be medically necessary
  • Choose a doctor, surgical team, and rehab facility that accept Medicare assignment or are within your Medicare Advantage network
  • Talk to your insurer to see if any preauthorization is needed
  • Discuss the costs with your doctor and insurer so you know what to expect

Does Medicare Pay for Rehab After Knee Replacement?

Most people who have knee replacement surgery need to receive rehab afterward to regain the normal use of their knee. There are a variety of factors that influence the type and length of rehab you’ll need, including your fitness level and the extent of the surgery. As a result, there are a lot of patients wondering “Does Medicare cover knee replacement rehab?”

Most people are able to go home after surgery and receive rehabilitation on an outpatient basis. This physical therapy is covered under Medicare Part B and you’ll pay 20% of the Medicare-approved cost after your deductible. There is no limit to medically-necessary physical therapy covered by Medicare.

In order to have inpatient rehabilitation covered, it needs to meet several criteria. First, it needs to be medically necessary, and you need to be at an inpatient rehab facility that accepts assignments from Medicare or is within your Medicare Advantage provider network. It also needs to come after a qualifying hospital stay.

If you have Original Medicare, your costs are the same as they are for an inpatient hospital stay under Medicare Part A. That means after day 90 within a year, you will pay the full costs of treatment unless you use lifetime reserve days.

Learn More About Medicare and Knee Replacement

This guide answered most of the common questions about Medicare and knee replacement, but you might have more concerns about your specific situation. If so, or if you’d like to compare Medicare plans to ensure you have the best coverage for your needs, contact us today!

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