Does Medicare Cover Hip Replacement Surgery?

Yes, Medicare covers hip replacement surgery when your doctor determines it is medically necessary. If you are dealing with severe joint pain that limits your daily activities and other treatments haven't worked, Medicare Part A and Part B will help pay for the procedure, the hospital stay, and your recovery.

When you are looking at a major procedure like a hip replacement, you need to understand exactly how your coverage works. The way your bills are paid depends entirely on which Medicare path you chose: Traditional Medicare (often paired with a Medigap plan) or Medicare Advantage.

If you are on the Traditional Medicare path, Part A covers your inpatient hospital stay. You will be responsible for the Part A deductible [as of 2024, varies by location and age]. Part B covers the surgeon's fees, anesthesia, and any outpatient physical therapy you need after the surgery. For these Part B services, Medicare pays 80% of the approved amount, and you are responsible for the remaining 20% after you meet your Part B deductible.

This is where the rubber meets the road. If you have Traditional Medicare and a Medigap plan, that 20% gap is covered. You won't be hit with surprise bills or network restrictions. You can use any surgeon and any hospital in the country that accepts Medicare. You protect what you've earned by capping your out-of-pocket costs.

If you chose the Medicare Advantage path, your coverage works differently. Medicare Advantage plans are required to cover everything that Traditional Medicare covers, including medically necessary hip replacements. However, your costs and rules are dictated by the private insurance company running your plan.

With Medicare Advantage, you will typically pay a copayment for the hospital stay and a separate copayment for the surgeon. You must also use the plan's network of doctors and hospitals, and you will likely need prior authorization before the surgery can be scheduled. Your total costs will count toward your plan's maximum out-of-pocket limit.

After your surgery, you will need physical therapy. Both Traditional Medicare and Medicare Advantage cover outpatient physical therapy. Under Traditional Medicare, Part B covers 80% of the cost, and your Medigap plan covers the rest. Under Medicare Advantage, you will pay a copay for each therapy session.

If your doctor determines you need to recover in a skilled nursing facility, Medicare Part A covers up to 100 days per benefit period, provided you meet the qualifying criteria. For the first 20 days, Medicare pays the full cost. From days 21 to 100, you pay a daily coinsurance amount [as of 2024, varies by location and age]. Again, a Medigap plan can cover this coinsurance, while a Medicare Advantage plan will have its own daily copay structure.