When your hip joint is damaged or worn, you may need hip replacement surgery. Osteoarthritis is the most common reason for a hip replacement. However, hip joint damage can also be caused by rheumatoid arthritis, a hip fracture, and other conditions.
In this MedicareWire article, we’ll examine how Medicare covers hip replacements and what you can expect to pay out of pocket for the procedure.
Key Takeaways
- A hip replacement involves replacing damaged portions of the hip joint with a prosthetic.
- Medicare Part A will cover costs for a hip replacement that requires a hospital stay for proper recovery.
- Medicare Part B will cover post-surgery costs once you are discharged from the hospital, as well as your hip replacement if you received it in an outpatient surgery center.
- Part D plans will cover any prescription drugs you need, such as post-surgery medication for your hip replacement.
- Medigap plans will help you with out-of-pocket costs after Medicare has paid its share, which can be huge for helping with post-surgery costs.
- Medicare Advantage plans will cover hip replacement surgeries, but the out-of-pocket costs can vary wildly compared to Original Medicare.
What Is Hip Replacement Surgery?
A hip replacement procedure is when a surgeon cuts across the side of the thigh to remove the damaged parts of the hip joint and replace them with an artificial prosthesis. The prosthesis could be made of metal, plastic, and/or ceramic, and provides the same hip movement function as your original hip. The new hip should help you by:1Niams.nih.gov, “What is hip replacement surgery?”, Accessed December 29, 2021
- Reducing pain caused by the damaged and/or diseased hip
- Increase hip flexibility
- Allow you to be more mobile
There are several joint and bone conditions that can require you to get a partial or total hip replacement, such as:2Niams.nih.gov, “Why do people need hip replacement surgery?”, Accessed December 29, 2021
- Osteoarthritis
- Rheumatoid arthritis
- Osteonecrosis
- Bone fractures due to physical trauma, such as falling down
How Long Do I Need To Stay In The Hospital After Hip Surgery?
The National Institute of Arthritis and Musculoskeletal and Skin Diseases claims that most people needing hip replacement surgery typically stay in the hospital for a few days. However, some people may end up going home post-surgery if hospital care is not required. Depending on the level of recovery care you require after the surgery, either Medicare Part A and/or Part B will provide coverage.3Niams.nih.gov, “What can I expect after hip replacement?”, Accessed December 29, 2021
How Does Medicare Cover Hip Replacement Surgery?
If your hip replacement surgery is performed in an inpatient setting, Medicare Part A will pay its share for:4Medicare.gov, “Inpatient rehabilitation care”, Accessed December 29, 2021
- A semi-private room
- Meals
- Nursing care
- Medications administered as part of your inpatient treatment
- The surgical procedure
If you need skilled nursing care to recover after surgery, Medicare Part A pays its share for the first 100 days of care, including physical therapy.5Medicare.gov, “Skilled nursing facility (SNF) care”, Accessed December 29, 2021
What If I Don’t Need A Hospital Stay?
If your hip replacement surgery doesn’t require a hospital stay, you will likely receive it at an outpatient surgical center and return home afterward. If you have your surgery at an outpatient surgical center, Medicare Part B covers 80 percent of the cost. Medicare Part B also covers your doctor’s fees for pre-op and post-op visits, post-op physical therapy, and any durable medical equipment (cane, walker, etc.) you might need.6Medicare.gov, “Outpatient hospital services”, Accessed December 29, 20217Medicare.gov, “Physical therapy”, Accessed December 29, 20218Medicare.gov, “Durable medical equipment (DME) coverage”, Accessed December 29, 2021
Post-Surgery Medication
Your Medicare Part D plan covers post-operative drugs that are not covered by Medicare Part B. For a prescription drug to be covered by Part D, it must be self-administered.9Medicare.gov, “What Medicare Part D drug plans cover”, Accessed December 29, 2021 If you need a drug that requires a health care professional to administer it, such as injectables, then Part B would cover it instead10Medicare.gov, “Prescription drugs (outpatient)”, Accessed December 29, 2021.
Depending on the Part D plan, you may have to pay an annual deductible before the plan provides coverage, as well as a copayment for each covered prescription. The co-payment amount will depend on which tier the drug is ranked in your Part D plan’s formulary (drug list).9Medicare.gov, “What Medicare Part D drug plans cover”, Accessed December 29, 2021
Do Medicare Advantage Plans Cover Hip Replacements?
Medicare Advantage plans are required to cover all services that Original Medicare covers. So if you are a Medicare Advantage plan member, you can receive coverage for a hip replacement surgery. Check with your plan to determine your out-of-pocket costs, as they vary from plan to plan.13Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 29, 2021
Out-of-pocket cost variation can be especially high when it comes to services that require a hospital stay, such as certain hip replacement surgeries. If you would like to know more about Medicare Advantage and how often out-of-pocket costs exceed Original Medicare for hospital stays, you can read our article on the topic here.
Summary
Like most medically necessary services, Medicare covers hip replacement surgery if your doctor orders it. However, it is important to understand that surgeries are expensive, which means your out-of-pocket costs may also be high. With Original Medicare, you can protect yourself from high out-of-pocket costs with a Medicare supplement. With Medicare Advantage, you are automatically protected by the plan’s Maximum Out-of-Pocket (MOOP) limit.
Citations
- 1Niams.nih.gov, “What is hip replacement surgery?”, Accessed December 29, 2021
- 2Niams.nih.gov, “Why do people need hip replacement surgery?”, Accessed December 29, 2021
- 3Niams.nih.gov, “What can I expect after hip replacement?”, Accessed December 29, 2021
- 4Medicare.gov, “Inpatient rehabilitation care”, Accessed December 29, 2021
- 5Medicare.gov, “Skilled nursing facility (SNF) care”, Accessed December 29, 2021
- 6Medicare.gov, “Outpatient hospital services”, Accessed December 29, 2021
- 7Medicare.gov, “Physical therapy”, Accessed December 29, 2021
- 8Medicare.gov, “Durable medical equipment (DME) coverage”, Accessed December 29, 2021
- 9Medicare.gov, “What Medicare Part D drug plans cover”, Accessed December 29, 2021
- 10Medicare.gov, “Prescription drugs (outpatient)”, Accessed December 29, 2021
- 13Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 29, 2021