Medicare provides coverage for medically necessary orthopedic surgeries, such as knee or hip replacements, primarily through Part A (hospital services) and Part B (medical services). Understanding the specifics of this coverage can help beneficiaries navigate their healthcare options effectively.
Surgery coverage can be important for many people as they age due to potential new health issues, like knee or hip pain. Fortunately, Medicare, the federal health insurance program for people 65 and older, helps cover a wide range of medical services, including orthopedic surgeries.
The Medicare program is divided into four parts: Part A, B, C, and D. Part C is the Advantage plan program, while Part D is for medication coverage. However, Part A and Part B, also known as Original Medicare, are the foundational parts of Medicare coverage for medical services, including orthopedic surgery, that are medically necessary.
Medicare and Medical Necessity
The procedures Medicare covers are typically based on whether a service is medically necessary. Medicare defines medically necessary as items and services needed to treat, monitor, or diagnose a health condition per Medicare guidelines.
This definition encompasses many different services, like surgeries. So, if you need orthopedic surgery, Medicare will likely cover it if it is medically necessary for your health and well-being.
Medicare Part A and Orthopedic Surgery
Medicare Part A covers inpatient hospital stays for orthopedic surgery. It can also help cover stays and care in skilled nursing facilities, hospices, home health, and nursing homes.
While in a hospital, Part A will help cover room and board, meals, general nursing care, certain medications, and miscellaneous medical supplies and services.
Medicare Part A and Orthopedic Surgery Costs
Part A inpatient stays are measured by benefit periods. A benefit period starts the day you are admitted as an inpatient and ends once you haven’t received inpatient care for 60 consecutive days.
Each benefit period comes with costs, including a deductible and copayments. In 2024, there is a $1,632 deductible for day one through day 60. Days 61 through 90 have a $408 copay, while days 91 and above have a $816 copay, with a limit of 60 lifetime reserve days. Once you’ve used up the 60 reserve days, you’re responsible for all costs related to your surgery.
These costs can add up quickly, so you may consider enrolling in a Medicare Supplement (Medigap) plan to help. A Medigap plan will help cover some or all the costs associated with Part A stays, including the deductible and copays, depending on the plan you have.
Medicare Part B and Orthopedic Surgery
Medicare Part B helps cover medically necessary orthopedic procedures you receive in an outpatient setting. This can include an outpatient status within a hospital or a non-hospital outpatient facility.
Medicare Part B and Orthopedic Surgery Costs
Part B costs work differently from Part A. Some medical services are subject to the annual Part B deductible of $240 in 2024. Once you’ve paid the deductible, Part B will pay 80% of Medicare-approved services, while the remaining 20% is your responsibility, consisting of copays or coinsurance.
Fortunately, like with Part A, a Medigap plan will help you pay for some or all of the 20%, depending on your plan. For example, Medigap Plan G covers all your out-of-pocket costs once you’ve met the Part B deductible.
Medicare Advantage Plans and Orthopedic Surgery
Medicare Part C, or Advantage plans, work differently from Original Medicare. With an Advantage plan, you receive care through a private insurance carrier instead of the government.
However, Advantage plans must provide at least the same coverage as Original Medicare, so they will also help cover orthopedic surgeries. Most Advantage plans also include Part D (medication) benefits.
Medicare Advantage Plans and Orthopedic Surgery Costs
All Advantage plans price medical services differently. You’ll want to check your Advantage plan to see what a specific procedure will cost. You can do this by reviewing your plan’s Summary of Benefits.
Medicare Advantage Plans and Referrals
Some Advantage plans, like HMO policies, may require their members to obtain referrals before seeing a specialist. Even if your plan doesn’t require a referral, some offices may ask for one anyway, so it’s always a good idea to verify.
Medicare Advantage Plans and Prior Authorization
Another point to keep in mind is that some Advantage plans may require prior authorization for certain services. This means your provider would have to receive approval from your Advantage plan before performing a medical service.
Medicare Part D and Orthopedic Surgery
Medicare Part D helps cover retail prescription medications from the pharmacy. Depending on the medication, Part D may also cover medications you receive for orthopedic surgery.
For example, if you take a self-administered drug, it may fall under Part D, even if you are an inpatient or outpatient.
Medicare Part D and Orthopedic Surgery Costs
Like Advantage plans, Part D costs depend on your specific plan. You can review which medications are covered under your Part D plan by referring to its drug formulary, which should also show costs.
If you take a Part D medication for orthopedic surgery, you may need to pay the full cost upfront and then submit a request for reimbursement from your plan.
Summary
As people age, they may need orthopedic surgeries for issues like knee or hip pain. Fortunately, Medicare helps cover these needs.
Original Medicare (Part A and Part B) covers orthopedic surgery if the procedure is medically necessary, with specific costs and copays. Exact costs depend on different factors, such as the procedure being done and your Medicare plans, such as a Medigap plan.
Medicare Advantage (Part C) plans offer similar coverage but may have different costs, referrals, and authorizations. Part D covers medications, including some that may be needed for surgery.
