Does Medicare Cover Hip Replacement Surgery?

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 MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. 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 AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. will cover costs for a hip replacement that requires a hospital stay for proper recovery.
Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. 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 costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. after Medicare has paid its share, which can be huge for helping with post-surgery costs.
Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover hip replacement surgeries, but the out-of-pocket costs can vary wildly compared to Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage..

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:¹

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:²

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.³

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:⁴

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.⁵

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 equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. (cane, walker, etc.) you might need.⁶⁷⁸

Post-Surgery Medication

Your Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... 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.⁹ If you need a drug that requires a health care professional to administer it, such as injectables, then Part B would cover it instead¹⁰.

Depending on the Part D plan, you may have to pay an annual deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. before the plan provides coverage, as well as a copaymentA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service. for each covered prescription. The copayment amount will depend on which tier the drug is ranked in your Part D plan’s formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered. (drug list).⁹

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.¹³

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 necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. 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 supplementMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage.. With Medicare Advantage, you are automatically protected by the plan’s Maximum Out-of-Pocket (MOOP) limit.

Citations

1
Niams.nih.gov, “What is hip replacement surgery?”, Accessed December 29, 2021
2
Niams.nih.gov, “Why do people need hip replacement surgery?”, Accessed December 29, 2021
3
Niams.nih.gov, “What can I expect after hip replacement?”, Accessed December 29, 2021
4
Medicare.gov, “Inpatient rehabilitation care”, Accessed December 29, 2021
5
Medicare.gov, “Skilled nursing facility (SNF) care”, Accessed December 29, 2021
6
Medicare.gov, “Outpatient hospital services”, Accessed December 29, 2021
7
Medicare.gov, “Physical therapy”, Accessed December 29, 2021
8
Medicare.gov, “Durable medical equipment (DME) coverage”, Accessed December 29, 2021
9
Medicare.gov, “What Medicare Part D drug plans cover”, Accessed December 29, 2021
10
Medicare.gov, “Prescription drugs (outpatient)”, Accessed December 29, 2021
13
Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 29, 2021