Medicare Coverage for Joint Replacement and Orthopedic Surgery
Hip and knee replacements are among the most common surgeries for Medicare beneficiaries. Here is what Medicare covers, how costs differ by setting, and what to expect for recovery.
Medicare Coverage for Joint Replacement and Orthopedic Surgery
Hip and knee replacements are among the most common surgical procedures performed on Medicare beneficiaries -- over 400,000 are performed annually. Understanding Medicare's coverage for these procedures helps you plan financially and make informed decisions about your care.
What Medicare Covers for Joint Replacement
Medicare covers joint replacement surgery (hip, knee, shoulder, and other joints) when medically necessary. Coverage includes:
- The surgical procedure
- Anesthesia
- Hospital stay (if inpatient)
- Implant (prosthetic joint)
- Post-surgical care in the hospital
- Rehabilitation (inpatient rehab facility, skilled nursing facility, or home health)
- Outpatient physical therapy
Inpatient vs. Outpatient: A Critical Cost Difference
Joint replacement surgery is increasingly performed in outpatient settings -- and the cost difference to you can be substantial.
Inpatient joint replacement (Part A):
- Part A deductible: $1,340 (2018)
- Days 1-60: No additional cost
- All medications included in the hospital payment
- Typical patient cost: $1,340
Outpatient joint replacement (Part B):
- Part B deductible: $183 (2018)
- 20% of the facility fee (which can be $15,000-$25,000+)
- 20% of surgeon fee
- Medications billed separately
- Typical patient cost: $3,000-$6,000+
Why this matters: Medicare has been moving joint replacements to the outpatient setting. In 2018, CMS removed total knee replacement from the inpatient-only list, meaning hospitals can now perform it outpatient. Total hip replacement followed.
Ask your surgeon whether your procedure will be inpatient or outpatient -- and understand the cost implications before surgery.
Rehabilitation After Joint Replacement
Recovery from joint replacement requires significant rehabilitation. Medicare covers several options:
Inpatient Rehabilitation Facility (IRF): For patients who need intensive therapy (3+ hours/day) and 24-hour nursing care. Covered under Part A. Most joint replacement patients don't qualify for IRF -- they're discharged home or to a SNF.
Skilled Nursing Facility (SNF): For patients who need skilled nursing care and therapy but not the intensity of IRF. Covered under Part A after a qualifying 3-day inpatient hospital stay.
- Days 1-20: $0 (after Part A deductible)
- Days 21-100: $167.50/day coinsurance (2018)
Home health care: For patients who are homebound after surgery. Physical therapy, occupational therapy, and skilled nursing covered at 100% under Part B.
Outpatient physical therapy: For patients who can travel to a therapy clinic. Covered under Part B at 80% after the deductible.
The SNF Trap After Outpatient Surgery
Here's a critical issue: if your joint replacement is performed outpatient, you don't have a qualifying 3-day inpatient hospital stay -- which means Medicare won't cover SNF rehabilitation after surgery.
If you need SNF care after an outpatient joint replacement, you pay the full cost out of pocket -- which can be $7,000-$12,000 per month.
Discuss this with your surgeon before agreeing to outpatient surgery. If you anticipate needing SNF rehabilitation, inpatient admission may be more appropriate.
Medigap and Joint Replacement
Medigap Plan G covers the 20% Part B coinsurance for outpatient surgery and the Part A deductible for inpatient surgery. With Plan G, your out-of-pocket costs for joint replacement are minimal regardless of setting.
This is one of the clearest illustrations of why Medigap coverage is valuable -- a single joint replacement can cost $5,000+ out of pocket without supplemental coverage.
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.
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About the Author
William Gray
Independent Medicare BrokerUS Air Force Veteran · Florida Medicare Specialist
William Gray is an independent Medicare insurance broker based in Daytona Beach and Palm Coast, FL. A US Air Force veteran (A-10 crew chief, Germany), he spent years in corporate insurance before going independent to serve Florida seniors directly. He has helped more than 1,000 clients across Northeast Florida compare Medicare Advantage, Medigap, and Part D plans — always at no cost to the client.