by Russell Noga | Updated November 15th, 2023
If you’re considering hip replacement surgery, understanding how Medicare covers this procedure is crucial. One question that often arises is, “does Medicare cover hip replacement?”
With the rising costs of healthcare, being informed about your insurance options can help alleviate financial stress and ensure you receive the best care possible.
In this comprehensive guide, we’ll explore the ins and outs of Medicare coverage for hip replacement surgery, including hospitalization, outpatient procedures, prescription drugs, and additional insurance options. Let’s dive in!
- Original Medicare (Part A and Part B) typically covers hip replacement surgery if medically necessary, Out-of-pocket expenses still apply.
- Additional insurance options such as Medicare Advantage Plans and Medigap policies are available to cover costs associated with hip replacement surgery.
- Careful planning is essential for a smoother recovery process when navigating post-surgery expenses with the best plan chosen by considering factors such as coverage, cost, network etc.
Understanding Medicare and Hip Replacement Coverage
Hip replacement surgery is a common procedure involving the removal of diseased or damaged parts of the hip joint and their replacement with new, artificial components, also known as hip replacements. When it comes to medical insurance, you might wonder, “Does Medicare cover hip replacements?”
The answer is yes, Original Medicare (Part A and Part B) typically covers hip replacement surgery if it is deemed medically necessary by a physician. But what does “medically necessary” really mean, and what are the out-of-pocket costs you can expect?
Medicare’s coverage for hip replacement surgery and related out-of-pocket costs encompasses everything from:
- Prescription drugs
- Skilled nursing facility inpatient care
- Durable medical equipment
- Physical therapy
Bear in mind, out-of-pocket costs like deductibles and copayments will still apply. If you have a Medicare supplement plan, also referred to as a Medigap plan, it can assist with these costs.
The Medicare-approved amount for hip replacement surgery depends on the procedure location, whether it is conducted at an outpatient surgical facility or an inpatient facility.
Several factors, such as your medical insurance coverage and the cost of the procedure, will influence your out-of-pocket expenses for hip replacement surgery. To help you better understand these costs, let’s delve deeper into the different aspects of Medicare coverage for hip replacement surgery.
Medicare Part A Coverage
Medicare Part A provides coverage for hospitalization expenses, skilled nursing care, and physical therapy related to hip replacement surgery.
This means it covers certain expenses related to hospitalization during an inpatient stay at a Medicare-approved hospital, such as the cost of the room, nursing care, and meals. Medicare Part A also offers coverage for physical therapy subsequent to hip replacement surgery.
Skilled nursing care, which includes services provided by licensed nurses and therapists, is covered by Medicare Part A if a beneficiary has days remaining in their benefit period for the stay and it is a qualifying hospital stay. Medicare Part A provides coverage for up to 100 days of hospitalization for hip replacement surgery.
Being cognizant of these coverage limits is crucial when planning for your surgery and subsequent recovery.
Medicare Part B Coverage
Medicare Part B encompasses outpatient procedures, physical therapy, and durable medical equipment associated with hip replacement surgery. This means that if your surgery is performed on an outpatient basis, Medicare Part B will typically cover it, provided it is deemed medically necessary by a doctor.
In addition, Medicare Part B provides coverage for durable medical equipment (DME) related to hip replacement surgery, such as canes, walkers, and other medically necessary equipment.
Medicare Part B also covers outpatient physical therapy following hip replacement surgery if it is deemed medically necessary. Generally, the coverage encompasses 80% of the costs. Consider this when mapping out your recovery and rehabilitation post-surgery.
Medicare Part D Coverage
Medicare Part D is a prescription drug coverage option that you can purchase from a private insurance company as a separate option from Original Medicare. This coverage can be particularly helpful during hip replacement recovery, as it covers prescription drugs necessary for the recovery process.
Keep in mind, each Part D plan has its unique list of approved drugs, or formulary, dictating which medications are covered. The formulary may vary between plans, but it must incorporate drug classes encompassing all disease states and a minimum of two chemically distinct drugs in each class.
Non-formulary drugs may still be covered under Part D, yet they are not included in a particular plan’s formulary. Scrutinizing your specific Medicare Part D plan for coverage details and any possible restrictions is absolutely essential.
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Additional Insurance Options for Hip Replacement Surgery
If you’re looking for more comprehensive coverage for your hip replacement surgery, you might consider additional insurance options such as Medicare Advantage (Part C) and Medigap policies. These options can help cover hip replacement surgery costs and provide additional benefits.
Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies and must provide coverage at least equivalent to that of Original Medicare (Parts A and B).
In many cases, Medicare Advantage plans may provide additional benefits beyond those provided by Original Medicare, such as:
- Nonemergency transportation to medical visits
- Meal delivery to your home after inpatient discharge
- Other services that may be necessary after hip replacement
On the other hand, Medigap policies are Medicare supplement plans that provide coverage for the gaps in Original Medicare. They can help pay for co-pays, coinsurance, and excess charges related to hip replacement surgery but do not cover the cost of the surgery itself.
Medicare Advantage Plans
Medicare Advantage is an alternative to traditional Medicare. It is offered by approved private insurance companies.
These plans typically offer supplementary benefits beyond those provided by Original Medicare, such as prescription drug coverage and aid with premium payments.
Regarding hip replacement surgery, Medicare Advantage Plans cover the costs of the procedure, including medicare cover hip replacement aspects such as:
- Doctor visits
- Surgery costs
- Physical therapy associated with the procedure
While the coverage may vary depending on the particular plan, it’s important to review the details of each Medicare Advantage Plan to comprehend the specific coverage and costs for hip replacement surgery.
Medigap policies, also known as Medicare supplement insurance, assist beneficiaries in covering the expenses not covered by Original Medicare following healthcare. These policies can help with co-pays, coinsurance, and excess charges associated with hip replacement surgery but, as mentioned earlier, do not cover the cost of the surgery itself.
By conversing with a licensed Medicare agent prior to enrolling in a Medigap plan, you can identify your healthcare needs, such as a hip replacement, and select a plan that keeps you covered at a reduced cost.
This additional coverage can be invaluable when navigating the complex world of healthcare costs and insurance coverage for hip replacement surgery.
Hip Injections and Medicare Coverage
Besides surgery, other treatments for hip pain may include hip injections, such as cortisone and Viscosupplementation injections. These injections of medications are administered into the hip joint to alleviate pain and inflammation.
Medicare Part A and Part B typically cover cortisone injections for hip pain, with coverage for up to three injections per year.
Viscosupplementation, on the other hand, is the injection of hyaluronic acid into the hip joint to reduce pain and inflammation. Medicare Part B may offer coverage for Viscosupplementation injections if they are deemed medically necessary.
Understanding your available options and ensuring you’re getting the right treatment for your hip pain is vital.
Comparing Costs: Hip Replacement Surgery and Medicare
Grasping the costs entailed in hip replacement surgery and the proportion covered by Medicare is essential when preparing for this procedure.
Here are some key points to consider:
- The average cost of hip replacement surgery in the United States is estimated to be around $39,880, although prices may vary from $18,175 to $53,750.
- Medicare generally covers 80% of the expenses associated with hip replacement surgery.
- This means that the individual is responsible for the remaining 20% of the costs.
The precise coverage amount may vary, but Medicare Part B generally covers 80% of the costs, leaving the individual responsible for the remaining 20%. In contrast, the out-of-pocket costs for those without insurance can range from $30,000 to $112,000 on average.
This cost comparison underscores the significance of possessing comprehensive insurance coverage when planning to undergo hip replacement surgery.
Average Costs of Hip Replacement Surgery
The cost of hip replacement surgery in the United States ranges from $30,000 to $112,000, depending on various factors.
Some of the elements that influence the cost of hip replacement surgery in the US include:
- Billing practices
- Implant prices
- Hospital charges
- Expenses for services post-surgery
- The surgeon’s fees
- The facility where the surgery is conducted
- Diagnostic tests
- Surgical implants
The aggregate cost of a hip replacement surgery generally incorporates the following:
- The specialist’s expense
- Anesthesia charges
- Medical clinic expenses
- Pre-operative and post-operative care
- Clinical supplies
- The expense of the embed
Being aware of potential costs can facilitate a more effective plan for your surgery, ensuring the required coverage and financial resources are in place.
Medicare’s Share of Costs
Medicare generally covers 80% of the cost of hip replacement surgery, with the patient responsible for the remaining 20%. Medicare Part A covers hospitalization costs, while Part B covers the medical care and medications related to the procedure.
The out-of-pocket costs for individuals with Medicare are significantly lower than those without insurance.
Awareness of the specificity in costs, which may be influenced by factors like your Medicare plan type and surgery specifics, is important.
Therefore, it is recommended to seek advice from your Medicare plan provider or review the specific coverage details of your plan for further information on the costs associated with hip replacement surgery.
Navigating Post-Surgery Expenses
After hip replacement surgery, you’ll need to navigate various post-surgery expenses, such as follow-up medical visits, physical therapy, and prescription medications. Medicare does offer coverage for post-surgery expenses, with Medicare Part A covering inpatient hospital stays and Part B covering outpatient rehabilitation, including physical therapy.
Insurance options like Medicare Advantage Plans and Medigap Policies can also be utilized to cover post-surgery expenses. Recognizing these extra expenses and planning accordingly is key to ensuring a stress-free recovery with minimal financial burden.
Physical Therapy and Rehabilitation
Physical therapy and rehabilitation after hip replacement surgery is a form of medical care that assists individuals in recuperating from hip replacement surgery.
Medicare covers physical therapy following hip replacement surgery as part of rehabilitation.
There is no explicit limit on the amount of days Medicare will cover outpatient rehab therapy.
In a skilled nursing facility, Medicare covers rehabilitation for up to 100 days, with no additional payment necessary for the first 20 days and a daily copayment potentially applicable afterward. When mapping out your recovery post-surgery, it’s vital to understand the coverage limits and potential costs linked to physical therapy and rehabilitation.
Prescription Medications and Pain Management
Medicare Part D covers prescription medications and pain management for hip replacement recovery.
Following hip replacement surgery, prescription medications that are typically necessary include:
- Pain medications
- Anti-inflammatory medications
- Muscle relaxants
It is important to note that coverage may differ depending on the particular medication and plan, so it is crucial to review your Medicare Part D plan’s formulary or contact your plan directly for further information on coverage for pain management medications after a hip replacement.
As part of the recovery process, it’s imperative that you have adequate coverage for prescription medications and pain management.
Choosing the Best Medicare Plan for Hip Replacement Surgery
Choosing an apt Medicare plan for your hip replacement surgery is critical to guarantee optimum care while minimizing your out-of-pocket expenses.
To choose the best plan, consider factors such as:
- Second opinion coverage
- Medical necessity
- Additional benefits
While comparing Medicare plans, note that both Medicare Advantage and Original Medicare extend coverage for hip replacement surgery. However, the coverage and costs may vary depending on the particular plan, so it’s important to review the details of each Medicare plan to comprehend the specific coverage and costs for hip replacement surgery.
Comprehending the coverage provided by different plans like Original Medicare, Medicare Advantage, and Medigap policies empowers you to make an informed decision on the plan most suitable for your hip replacement surgery and overall healthcare needs. This will help you minimize your financial burden and ensure a smooth recovery process.
In conclusion, understanding Medicare coverage and the various insurance options available for hip replacement surgery is vital for ensuring you receive the best care possible while minimizing your out-of-pocket expenses.
By exploring Original Medicare, Medicare Advantage, and Medigap policies, and considering factors such as coverage, cost, and additional benefits, you can make an informed decision about the best plan for your hip replacement surgery.
Armed with this knowledge, you can focus on your recovery and regain the mobility and quality of life you deserve.
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Frequently Asked Questions
What percentage does Medicare pay on hip replacement?
Medicare typically covers 80% of the costs for hip replacement surgery, leaving the patient responsible for the remaining 20%.
What makes a hip replacement medically necessary?
Hip replacement surgery is an option when hip pain interferes with daily activities and other treatments are no longer effective. The most common reason for needing it is arthritis damage, but it can also be caused by conditions such as rheumatoid arthritis, osteonecrosis, or post-traumatic arthritis, which results in severe pain, stiffness and difficulty walking.
What is the average total cost of hip replacement?
On average, a total hip replacement surgery for an uninsured patient will cost around $40,000, ranging from $31,000 to $45,000. Insurance coverage may reduce out-of-pocket costs for eligible patients.
How long does it take to walk normally after a hip replacement?
With individual healing progressions in mind, it typically takes 2-3 weeks after surgery to discontinue using crutches or a walker and around 6 weeks post-op to resume activities such as walking normally and driving.
What are the out-of-pocket costs for hip replacement surgery for individuals with Medicare?
For individuals with Medicare, out-of-pocket costs for hip replacement surgery will typically amount to 20% of the total expenses.
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.