Medicare Coverage for Joint Replacement Surgery: Hip, Knee, and Shoulder

Joint replacement surgery -- hip, knee, and shoulder -- is among the most commonly performed procedures in Medicare. More than 1 million joint replacements are performed on Medicare beneficiaries each year. Medicare covers the full continuum of joint replacement care, from pre-operative evaluation through post-surgical rehabilitation.

Before joint replacement surgery, Medicare covers the pre-operative workup:

• Orthopedic surgeon consultations and evaluations
• X-rays and MRI of the affected joint
• Pre-operative lab tests and EKG
• Anesthesia pre-operative evaluation
• Physical therapy evaluation (in some cases)

Cost: 20% coinsurance after the Part B deductible. Medigap Plan G covers this 20%.

Joint replacement surgery can be performed as an inpatient admission (Part A) or as an outpatient procedure (Part B), depending on your health status and the surgeon's judgment.

Inpatient (Part A): Historically, joint replacements required inpatient admission. Medicare removed total knee replacement from the inpatient-only list in 2018 and total hip replacement in 2020 -- allowing these procedures to be performed in outpatient settings.

• Part A covers the hospitalization (room, nursing, anesthesia, implant)
• Part B covers the surgeon's fee
• Cost: Part A deductible per benefit period ($1,556 in 2022) + 20% of surgeon fee

Outpatient (Part B): Outpatient joint replacement is increasingly common for healthy patients with good support at home.

• Part B covers the facility fee, surgeon fee, anesthesia, and implant
• Cost: 20% coinsurance after the Part B deductible

Medigap Plan G covers the Part A deductible and Part B coinsurance -- making joint replacement surgery essentially free beyond the annual Part B deductible.

After joint replacement, many patients transfer to an Inpatient Rehabilitation Facility (IRF) for intensive therapy -- typically 1-2 weeks.

Coverage: Part A covers IRF stays. Standard Part A cost-sharing applies (days 1-20 at no cost with Plan G).

Qualification: Patients must be able to tolerate at least 3 hours of therapy per day to qualify for IRF admission.

For patients who cannot tolerate IRF intensity, a skilled nursing facility provides less intensive post-acute rehabilitation.

Coverage: Up to 100 days per benefit period after a qualifying 3-day inpatient hospital stay. Days 1-20 at no cost; days 21-100 with daily coinsurance. Medigap Plan G covers the coinsurance.

Note: If surgery is performed as an outpatient procedure, there is no qualifying inpatient hospital stay -- and SNF coverage is not available. This is an important consideration when deciding between inpatient and outpatient surgery.

For homebound patients after joint replacement, Medicare covers home physical therapy, occupational therapy, and skilled nursing at no cost.

Once no longer homebound, outpatient physical therapy continues recovery -- typically 6-12 weeks of sessions. Covered at 20% coinsurance after the Part B deductible. Medigap Plan G covers this 20%.

Medicare covers DME needed after joint replacement:

• Walker or crutches
• Raised toilet seat
• Shower chair (in some cases)
• Continuous passive motion (CPM) machine (for knee replacement)

We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.