Does Medicare Cover Knee Replacement Surgery?

Yes, Medicare covers knee replacement surgery when your doctor determines it is medically necessary. If conservative treatments like physical therapy, medications, or injections haven't worked, and your knee pain is severely impacting your daily life, Medicare will help pay for the procedure.

When you're looking at a major procedure like a knee replacement, you need to understand how your coverage works. The way your surgery is covered depends entirely on which Medicare path you've chosen. Remember, the real choice isn't between a supplement and an Advantage plan - it's between Traditional Medicare (Parts A and B) and Medicare Advantage (Part C).

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

This is where a Medicare Supplement (Medigap) plan comes in. If you chose the Traditional path, a supplement fills the gaps by law. Depending on your Medigap plan, it can cover the Part A deductible, the 20% Part B coinsurance, and even excess charges. With a comprehensive Medigap plan, your out-of-pocket costs for a knee replacement could be very close to zero.

If you chose the Medicare Advantage path, your coverage works differently. Medicare Advantage plans must cover everything that Traditional Medicare covers, so your knee replacement will be covered if it's medically necessary. However, your costs and rules are set by the private insurance company, not the federal government. You will likely have to pay copayments or coinsurance for the hospital stay, the surgeon, and your physical therapy. You may also need prior authorization before the surgery, and you will usually need to use hospitals and doctors within the plan's network to get the best rates.

After your surgery, you will need physical therapy to regain your strength and mobility. Traditional Medicare Part B covers outpatient physical therapy, and Part A covers inpatient rehabilitation if your doctor says you need it. Again, if you have a Medigap plan, it will help cover the coinsurance for these services. Medicare Advantage plans also cover physical therapy, but you will have copays for each session and may be restricted to network providers.

Don't wait until you're scheduling surgery to figure out your coverage. If you're planning a knee replacement or just want to make sure you're protected for the future, we can help you review your options. We'll walk you through every option and make sure you have the right coverage for your needs.