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Does Medicare Cover Knee Replacement Surgery? What You Need to Know

5 mins read
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Knee replacement surgery is a marvel of modern medical technology that offers a renewed chance at mobility and enhanced quality of life for many. It’s a potentially life-changing procedure for individuals who have endured persistent knee pain or faced limitations in their daily activities due to knee-related ailments like osteoarthritis. 

For those who are eligible for Medicare, they’ll want to know if Medicare covers knee replacement surgery. This article provides clarity, so beneficiaries can make informed decisions about their healthcare needs. 

Understanding Knee Replacement Surgery

Considered a transformative procedure, knee replacement surgery directly addresses and alleviates the debilitating pain and loss of function from damaged knee joints. The procedure can be broadly classified into two main types:

  • Total Knee Replacement (TKR): As the name suggests, this involves replacing the entire knee joint. A surgeon removes damaged bone and cartilage from your thigh bone, shinbone, and kneecap, replacing it with an artificial joint made of metals and polymers. This is the most common form of knee replacement.
  • Partial Knee Replacement (PKR): This is a less invasive option suitable for patients with damage limited to one specific area of the knee. It involves replacing only the damaged portion while preserving as much of the natural knee structure as possible.

The necessity for knee replacement often arises from degenerative conditions. Chief among them is osteoarthritis, a wear-and-tear condition where the knee’s cushioning cartilage wears away, causing bone-on-bone friction, pain, and loss of mobility. Another significant condition is rheumatoid arthritis, an autoimmune disorder where the immune system attacks the lining of the joint capsule, leading to inflammatory arthritis of the knee.

With successful knee replacement, individuals can look forward to a dramatic reduction in knee pain, a significant improvement in movement, and an enhanced quality of life. 

Overview of Medicare Coverage for Knee Replacement Surgery

Understanding Medicare’s structure and coverage is important when considering procedures like knee replacement surgery. Here’s how it works:

Medicare Part A: Hospital Coverage

When you undergo knee replacement surgery as an inpatient, it’s covered under Medicare Part A (Hospital Insurance). It includes:

  • Hospital stays: This covers your inpatient accommodation, which generally includes a semi-private room, nursing services, meals, and any necessary treatments or medications received during your stay.
  • Pre-surgery hospitalization: Sometimes, you may need to admit yourself a day before the surgery for necessary preparations and consultations. Part A covers this as well.
  • Post-surgery care: After your operation, you might require a few days of hospitalization to monitor your recovery, manage postoperative pain, and initiate physical therapy. These days are also covered under Part A.

Medicare Part B: Medical Services Coverage

While Part A covers the hospital-related aspects, Medicare Part B (Medical Insurance) comes into play for the outpatient medical services surrounding your knee replacement. Coverage extends to:

  • Surgeon and physician fees: In an outpatient setting, the fees charged by your orthopedic surgeon for performing the procedure and any other consulting physicians fall under Part B.
  • Pre-surgery consultations: Before your surgery, there will be appointments with your surgeon to discuss the procedure, potential risks, and post-surgery care. Part B covers these consultations.
  • Post-operative care: Part B covers follow-up visits to your surgeon to monitor healing and address any postoperative complications that may arise.
  • Anesthesia: Part B covers the costs related to the administration of anesthesia during the surgery.
  • Outpatient services: If your knee replacement surgery occurs on an outpatient basis, Part B will cover the services.

Make sure to consult with your healthcare provider and understand the entirety of the procedure and recovery process. This is vital to ensuring you’re well-informed about what Medicare covers and where you might be liable for out-of-pocket expenses.

Eligibility Criteria and Medical Necessity

Knee replacement is a significant procedure and may not be the right fit for everyone. As a result, Medicare insists upon the medical necessity of the surgery before entertaining claims.

Here’s what you need to know:

  1. Initial screening and treatment: Before considering knee replacement, a beneficiary must undergo necessary screenings and treatment by a Medicare-approved primary care physician. This process helps identify the severity of the knee condition and maps out possible non-surgical interventions.
  2. Consultation with an orthopedic specialist: Based on the initial assessment, your primary doctor might refer you to an orthopedic specialist. This specialist will delve deeper into understanding the intricacies of the damage, pain, and mobility limitations.
  3. Criteria for surgery: The primary indicators for knee replacement surgery are severe pain and significant mobility limitations. Conditions where beneficiaries find walking, climbing stairs, and simple movements challenging, or if there’s persistent knee pain even during rest, are often deemed fit for the surgery.
  4. Medically necessary determination: The term “medically necessary” is critical. The decision to undergo knee replacement involves a holistic view. The doctor assesses the extent of the damage, the impact on the quality of life, the potential risks and benefits of the surgery, and whether they have exhausted alternate treatments.
  5. Communicating with Medicare: Post-assessment, the doctor communicates the findings and recommendations for surgery to Medicare. This is a crucial step, as Medicare’s approval hinges on.

Costs and Out-of-Pocket Expenses

While Medicare offers extensive coverage for approved procedures, beneficiaries must prepare for some out-of-pocket expenses. It’s necessary to understand these costs to prevent unforeseen financial strain.

  1. Understanding deductibles: Medicare coverage kicks in after the payment of set deductibles. For knee replacement surgery, depending on whether it’s an inpatient or outpatient procedure, you’ll have to meet the respective Part A or Part B deductibles.
  2. Copayments and coinsurance: Even after Medicare starts covering the costs, beneficiaries are typically liable for certain copayments or coinsurance. Under Medicare Part B, for instance, beneficiaries pay 20% of the approved cost after meeting their deductible, while Medicare takes care of the remaining 80%. 
  3. Managing costs: It’s important to discuss potential out-of-pocket costs with both the healthcare provider and the insurer. Having a clear cost breakdown helps in financial planning. Beneficiaries can also explore supplemental insurance plans that might cover some of these out-of-pocket expenses.
  4. Choosing the right procedure: Discuss with your physician the differences in terms of costs and recovery periods between full and partial knee replacement. Understanding these nuances ensures you’re making informed decisions, both medically and financially.
  5. Post-surgery costs: Post-operative care, medications, physical therapy, and any required equipment (like canes or walkers) might add to the overall costs of knee replacement surgery. While Medicare covers many of these, it’s essential to factor in potential coinsurance or copayments.

Rehabilitation and Follow-Up Care

Rehabilitation is an integral part of the recovery process after knee replacement surgery. It ensures the newly replaced joint is functional and allows individuals to return to their daily routines. It aids in strengthening the knee, reducing the risk of complications, and ensuring the longevity of the replacement. Here’s how Medicare steps in to aid in this post-operative phase:

  • Physical therapy: Medicare Part B covers necessary physical therapy sessions post-surgery, which are pivotal in enhancing mobility, strength, and joint flexibility.
  • Skilled nursing facilities: If a patient requires supervised recovery, Medicare Part A may cover a temporary stay in a skilled nursing facility. During this stay, beneficiaries can avail of various medical services, from medications to clinical tests.
  • Home health care: For those who can recover at home but require specialized care, Medicare may cover home health care services. This can include periodic visits from healthcare professionals to monitor the knee’s progress and provide necessary treatments.

While Medicare covers many aspects of rehabilitation, the duration and extent of coverage may vary based on individual needs and medical recommendations. Make sure to consult with your healthcare provider for clarity on the number of sessions or care days that may be required and the potential out-of-pocket costs involved.

At CoverRight, we’re here to help you navigate your Medicare options for optimal coverage. Reach out to us to explore, compare, and confidently choose the right plan for your knee replacement needs.

Frequently asked questions

Can I choose where to have the surgery?

Yes, patients generally have the autonomy to select their preferred hospital or surgical center, provided it’s Medicare-approved. 

What if I need a second knee replacement?

Should you require a second knee replacement, either on the same knee (revision surgery) or the other knee, Medicare will typically cover the procedure if it’s deemed medically necessary. The terms of coverage, including eligibility criteria and out-of-pocket costs, usually align with those of the first surgery. Always consult with your doctor and Medicare provider to understand the specifics.

Richard Chan

Richard is the Founder of CoverRight and based in New York. He is passionate about empowering consumers to take control of their health and finances. Prior to starting CoverRight, Richard had extensive experience working in financial services with over 8 years' experience in consumer lending and investment banking.

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