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Understanding Medicare Coverage for Knee Replacement Surgery

Knee replacement surgery, also called knee arthroplasty, is a procedure where a surgeon removes damaged portions of your knee joint and replaces them with artificial parts made of metal and plastic. According to the American Academy of Orthopaedic Surgeons, more than 750,000 knee replacement surgeries are performed in the United States each year. Medicare, the federal health insurance program for people age 65 and older and some younger people with disabilities, covers many aspects of knee replacement procedures.

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When you have severe knee damage from arthritis, injury, or other conditions, your doctor might recommend knee replacement surgery as a treatment option. Before surgery can happen, you typically need X-rays, blood tests, and possibly other imaging to confirm the damage and plan the procedure. Medicare Part B generally covers the surgeon's fees, the operating room, anesthesia, and related medical services during the hospital stay.

The coverage structure for knee replacement involves different parts of Medicare working together. Medicare Part A covers inpatient hospital care, which includes the surgery itself, your hospital bed, meals, and nursing care during your stay. The average hospital stay for knee replacement is one to three days. Medicare Part B covers the surgeon's services and other outpatient services related to your surgery.

It's important to understand that Medicare coverage varies depending on whether your procedure is done as an inpatient (you stay overnight in the hospital) or outpatient (you go home the same day) surgery. The type of facility also matters—hospital-based surgery centers may have different cost-sharing requirements than independent surgical centers.

Practical Takeaway: Learning how Medicare's different parts cover various aspects of knee replacement helps you understand which costs Medicare pays and which you may pay yourself. Review your surgery plan with your healthcare provider to understand whether your procedure will be inpatient or outpatient, as this affects your costs.

What Costs You Might Pay Out-of-Pocket

Even with Medicare coverage, you will likely have some out-of-pocket costs for knee replacement surgery. Understanding these costs helps you plan financially for your procedure. Your costs depend on your specific Medicare coverage and whether you have additional insurance.

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If your knee replacement is done as an inpatient procedure at a hospital, Medicare Part A requires you to pay a deductible. For 2024, the Part A inpatient deductible is $1,632 per benefit period. After you pay this deductible, Medicare covers all covered costs for days 1 through 60 of your hospital stay. If you stay longer than 60 days, you pay coinsurance—a daily amount—for days 61 through 90.

Medicare Part B also has costs. Part B requires you to pay a monthly premium (for 2024, the standard premium is $174.70, though this varies based on income), and you pay an annual deductible ($240 for 2024). After meeting your Part B deductible, you typically pay 20 percent of the approved amount for doctor services and outpatient care related to your surgery.

Additional costs may include:

• Prescription medications after surgery (covered by Medicare Part D, your prescription drug plan)
• Physical therapy and rehabilitation services (Medicare Part B covers these after surgery, though you pay 20 percent coinsurance after meeting your deductible)
• Durable medical equipment like crutches, walkers, or a knee brace (Medicare Part B covers 80 percent after you meet your deductible)
• Any services or items not covered by Medicare

If you have supplemental insurance (also called Medigap) or Medicare Advantage coverage, your out-of-pocket costs may be different. Medigap plans can help cover some costs that original Medicare doesn't, while Medicare Advantage plans have different cost structures entirely.

Practical Takeaway: Before surgery, ask your healthcare provider's billing department for an estimate of your costs. Contact your Medicare plan to confirm what you'll pay. If costs concern you, discuss payment options or financial programs with your provider's office.

How to Review Your Medicare Coverage Details

Your Medicare coverage for knee replacement depends on the specific coverage you have. Medicare comes in different forms—original Medicare (Parts A and B), Medicare Advantage (Part C), or combinations with supplemental coverage. Each type has different rules about what's covered and what you pay.

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If you have original Medicare, your coverage for knee replacement is determined by Medicare's national coverage rules and any local rules in your area. Your Medicare Summary Notice, which you receive quarterly, shows your claims and what Medicare paid. You can also review your coverage details by visiting Medicare.gov or calling 1-800-MEDICARE (1-800-633-4227).

If you have a Medicare Advantage plan (often called Part C), your plan may cover knee replacement differently than original Medicare. Some Medicare Advantage plans cover additional services or have lower out-of-pocket costs, but others may require prior authorization before surgery. You should contact your plan directly to understand exactly what's covered for your knee replacement.

Before having surgery, your surgeon's office typically checks whether your Medicare coverage authorizes the procedure. This process, called prior authorization or pre-authorization, happens behind the scenes in most cases. Your surgeon's office contacts your insurance to confirm the surgery is covered. If your coverage requires prior authorization and the surgery proceeds without it, you could be responsible for the full cost, so it's good to confirm this step happens.

Key documents that show your coverage information include:

• Your Medicare card, which shows whether you have original Medicare or Medicare Advantage
• Your Explanation of Benefits (EOB), sent after claims are processed
• Your Summary of Benefits and Coverage (SBC), which outlines what your plan covers
• Your plan documents or formulary (for prescription medications)

Practical Takeaway: Gather your Medicare documents and contact your plan before your surgery to confirm coverage. Ask specifically whether prior authorization is needed and what your out-of-pocket costs will be for the entire surgical episode, including pre-surgery testing, the surgery itself, and post-surgery care.

Information About Pre-Surgery Requirements and Testing

Before knee replacement surgery, you'll need several tests and appointments to prepare. Medicare covers many of these pre-operative services, which helps reduce your costs. Understanding what to expect helps you prepare physically and mentally for surgery.

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Your primary care doctor typically performs a pre-operative evaluation, which includes a medical history review, physical exam, and sometimes blood work and an EKG (heart test). This appointment, usually done within 30 days before surgery, confirms that you're healthy enough for surgery and anesthesia. Medicare Part B covers this visit, and you pay your usual coinsurance.

Imaging studies are usually needed to show the exact damage in your knee. X-rays are the standard imaging and cost relatively little. Sometimes your surgeon orders an MRI (magnetic resonance imaging) to see soft tissues like cartilage and ligaments. An MRI costs more but provides detailed images. Medicare Part B covers these imaging services when ordered by your doctor, and you typically pay 20 percent of the approved amount after meeting your deductible.

Blood tests check your blood counts, kidney and liver function, and clotting ability. These tests ensure you can safely undergo surgery and anesthesia. Blood work typically costs $100 to $300 with Medicare, as Medicare covers the lab work and you pay coinsurance.

Additional pre-operative testing may include:

• EKG or heart monitoring if you have heart concerns
• Chest X-ray if you have lung or breathing issues
• Urinalysis to check for infection
• Medication review with your surgeon and anesthesiologist
• Physical therapy evaluation to establish a baseline for post-surgery rehabilitation

You'll also meet with your anesthesiologist before surgery to discuss anesthesia options and any concerns. This consultation is covered by Medicare Part B.

Practical Takeaway: Schedule your pre-operative appointments at least 4-6 weeks before your planned surgery date. Bring a list of all medications you