Medicare Total Knee Replacement 2020

Medicare Advantage Plans Cover Knee Replacement And Have Out

If you have a Medicare Advantage plan, your plan will offer the same benefits as Original Medicare. Medicare Advantage plans also include out-of-pocket spending limits, which could help you pay less out of pocket for your knee replacement surgery.

For both Original Medicare and Medicare Advantage plans, deductibles, coinsurance and copayments may apply.

Knee replacement surgeries are common in the United States. According to Forbes, more than one million knee replacement procedures were completed between 2005 and 2015. Many of the people who received these surgeries were Medicare beneficiaries.1

If you receive the surgery in an ambulatory surgery center or outpatient setting, you may pay a different amount.

Medicare Now Covers Same

Beginning this year, Medicare will cover total hip replacement performed at Ambulatory Surgical Centers , such as St. Cloud Surgical Center.

In the past, total hip replacement surgeries have required extended stays in the hospital or a rehab facility while the patient recovers. Now, better anesthesia techniques, surgical techniques, and improvements in prosthetic implants have significantly reduced the recovery time after a joint replacement. This means that extensive hospital stays are no longer required for post-operative rehabilitation.

Factors Influencing DecisionThe number of total hip and total knee replacement cases is projected to increase from 1.1 million to approximately 1.9 million by 2026, and 51% of primary hip and knee replacements are expected to be performed in the outpatient setting.

Many factors have contributed to the migration of joint replacement cases out of the hospital setting:

Find out what this new rule means for you, and if you are a candidate for outpatient joint replacement.What does this new Medicare rule mean?

• The new Medicare rule represents a recognition that patients often recover from surgery better in their own homes and that extensive hospital stays are no longer required for post-operative rehabilitation.
• This gives patients more options in choosing the location, quality of care, and the ability to save in the cost of their care.

What are the benefits of outpatient joint replacement?

Am I a candidate for outpatient joint replacement?

What Is The Cost Of Knee Replacement In Other Countries

For American patients without health insurance, it might be worth considering medical tourism, i.e., leaving the country for knee replacement surgery. Many countries in the world offer this procedure for costs dramatically lower than those in the United States. We have listed knee replacement cost estimates from various medical tourism destinations in the chart below. The cost of total knee replacement surgery will also vary from patient to patient, depending on factors such as age and medical history.

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More Questions About Knee Replacement Costs Heres What You Can Do Next

Choosing to have a knee replacement is a big decision. And its important to understand early on what it might cost, so you can feel confident going into your surgery.

If you have more questions, heres where you can look for further answers:

• The representative you talk with should be able to give you a detailed look at your coverage. You can also tell them youre considering surgery with TRIA, and that may help them give you more detailed estimate of your potential costs.
• Talk with a representative in TRIAs Patient Financial Services department. If youre having surgery at TRIA and have more questions, our financial services team can help. Call .

How Much Does Medicare Pay For Knee Replacement Surgery

Medicare typically covers a number of surgeries that are considered medically necessary, including knee and other joint replacement surgeries.

How much Medicare will pay for your knee replacement surgery depends on where you receive the procedure.

• If you get your surgery in a hospital and are admitted as an inpatient, you can expect both Medicare Part A and Part B to contribute. Part A will help pay your hospital costs, and Part B will cover medical costs associated with the procedure.
• An outpatient procedure will likely be covered under Part B.

Deductibles and coinsurance may apply, whether your surgery is covered under Part A or Part B.

• Part A requires a deductible of $1,408 per benefit period in 2020. You don’t pay coinsurance for the first 60 days of an inpatient hospital stay during a benefit period.
• Part B requires an annual deductible of $198 per year in 2020. After you meet your Part B deductible, you usually pay a coinsurance or copay amount that is typically 20% of the Medicare-approved amount.

A Medicare Supplement Insurance plan can help cover some of the out-of-pocket Medicare costs you may face for knee replacement surgery, such as the Part B coinsurance and your Part A deductible.

Medicare Advantage plans which are different from Medicare Supplement plans are required by law to provide all of the same basic benefits as Original Medicare, so a knee replacement surgery with a Medicare Advantage plan would come with identical coverage to the above.

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Surgeon Payments And Charges

Regarding surgeon reimbursements, Medicare payment per case decreased for TJA from 2012 to 2017, with an overall inflation-adjusted decrease of 14.9% . When comparing hip and knee arthroplasties, there is a significant difference in mean reimbursement per case, at $1207.75 and $1166.73, respectively . We found geographic variability in Medicare payments to surgeons. Mean reimbursements per case were on average higher in the Northeast and West compared with the South and Midwest . In addition, surgeons performing TJAs in metropolitan areas received significantly higher reimbursement per case compared with those performing TJAs in rural areas .

How Much Will Medicare Pay For Total Knee Replacement

If its an inpatient surgery, Medicare will cover most of the cost. Youll be responsible for the Part A deductible, as well as additional cost-sharing in the form of coinsurance. If its an outpatient surgery, Medicare will cover 80% of the cost.

Youll be responsible for the Part B deductible and 20% of the cost. Any prescriptions given at the hospital will also be covered under Part B. Any prescriptions that youre prescribed to take at home wont have coverage unless you have a stand-alone Part D plan. Or, if you have an Advantage plan that covered prescriptions.

If you have a Medigap plan, depending on the letter plan you enrolled in, you could have zero out of pocket costs for total knee replacement surgery. If you have a Medicare Advantage plan, youll have to check with the carrier you enrolled with to determine what youll have to pay out of pocket.

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What Types Of Outpatient Joint Surgeries Are Covered Through Medicare

• Medicare now classifies total knee and total hip surgeries as outpatient surgeries.
• The rule allows only total knee replacements to be done in a surgery center setting.
• Total hip replacements can be done outpatient in a hospital, and soon total hip replacements will be allowed in a surgery center setting.

Will Medicare Help Pay For A Knee Replacement

The cost of a knee replacement can be anywhere between $15000 to $30000. It is because of the high costs that the concerned authorities in the United States have implemented a new system for the Medicare coverage for knee replacement procedure and other similar in-patient surgeries such as hip replacement.

The changes have been designed to lower expenses and increase the success rate of the procedures. Some surgeons voiced their concerns about the new procedure eventually leading them to discourage patients from opting for the surgery due to their lower chances of success and recovery.

Hence, the new program was designed to emphasize quality over quantity for doctors and hospitals that perform knee replacements. The emphasis is particularly on reducing the post-surgical complications that can prevent speedy recovery of the patients while worsening the burden of expenses.

The changes in the program would be invisible to beneficiaries seeking Medicare coverage at the start. However, due to the cost and quality targets related to the hospital performance recommend in the new program, the future knee replacement seekers might find it difficult to receive Medicare reimbursement.

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Quality Measures For Utah Procedures

Separate from the cost associated with the procedure, another factor prospective hip or knee replacement patients may consider is the quality of outcome. Since the Utah All Payers Claim Database does not contain outcome information for procedures, the Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program database was used to explore how Utahs rates of readmissions after hip and knee replacements compare with the national average. As depicted below, the Utah rate of readmission after hip and knee replacement was 3.5%, which is slightly lower than the national rate of 4%.

A 2019 study on complications following hip and knee replacement surgeries indicates there may also be a difference in outcomes between sexes. The study found that while women experienced higher complication rates than men in general , men experienced higher rates of acute complications, including death, kidney injury, and cardiac arrest. Without access to similar statistics for the state of Utah specifically, our analysis is unable to determine whether these findings hold true for Utah patients as well.

Your Knee Replacement Surgery Classification

There are two types of knee replacement surgery classifications: Inpatient surgeries and outpatient surgeries.

Oftentimes, inpatient means youll have a hospital stay after surgery, and outpatient means youll be discharged the same day as your surgery. But that may not be how your insurance company classifies your surgery.

In fact, its very possible that a knee replacement surgery would be classified as an outpatient surgery. Many patients do go home the same day as their surgery if they meet certain criteria and their insurance covers it. But even if a patient spends a night in the hospital, its likely that their surgery will be considered outpatient. This can have an impact on the total amount youre responsible for.

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Do Medicare Advantage Plans Cover Knee Replacement Surgery

Medicare Advantage plans are health plans offered by private insurance companies that are Medicare-approved. MA plans, also known as Medicare Part C, bundle Medicare Part A and Medicare Part B coverage. As such, MA plans have the same covered services as Original Medicare, meaning knee replacement surgeries are covered.

That said, Medicare Advantage plans may provide additional benefits in addition to standard Original Medicare coverage. This may include prescription drug coverage and help with premium payments. These benefits may help lower a patients overall out-of-pocket costs associated with a knee replacement.

Find Medicare Advantage Plans That Cover Knee Replacements And More

Because Medicare Advantage plans must offer the same benefits as Medicare Part A and Medicare Part B, your Medicare Advantage plan should cover your knee replacement surgery if a doctor says it is medically necessary.

If youre eligible for Medicare enrollment or are interested in changing to a Medicare Advantage plan, call a licensed insurance agent today to see what Medicare Advantage plans are available in your area.

Find Medicare Advantage plans that cover knee replacement

Or call to speak with a licensed insurance agent. We accept calls 24/7!

1 Ubel, Peter. Medicare Is Reducing The Cost Of Knee Replacements . . Forbes. Retrieved from www.forbes.com/sites/peterubel/2017/02/10/medicare-is-reducing-the-cost-of-knee-replacements-heres-how-that-could-backfire/#279a55416392.

2 BlueCross BlueShield. . Planned knee and hip replacement surgeries are on the rise in the U.S. Retrieved from www.bcbs.com/the-health-of-america/reports/planned-knee-and-hip-replacement-surgeries-are-the-rise-the-us.

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelors degree in journalism.

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What Other Costs Should I Worry About

After you are discharged from the hospital, you will still need to be vigilant in caring for your new knee. You will likely be prescribed medications for pain and to reduce the risk of infection and blood clots. It is also very common to need physical therapy or rehabilitation after surgery, which can be costly depending on your coverage. Always consult with your doctor and insurance provider to make sure you know exactly what coverage you have before your surgery.

Office Of Health Care Statistics

According to the Centers for Medicare and Medicaid Services, hips and knees are the two most commonly replaced joints. Both of these surgeries are done to reduce patient pain and increase mobility. Although it is most common for seniors to require hip and knee replacements, other age groups may also need this type of surgery.

In this DataByte, we examine the prevalence of hip and knee surgeries in Utah over the past three years by various patient demographics. Additionally, we look at the normal/average cost range for these surgeries and compare Utah readmission rates with the national average. Any noticeable trends or differences between years are identified.

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What Does This New Medicare Rule Mean

• The new Medicare rule represents a recognition that patients often recover from surgery better in their own homes and that extensive hospital stays are no longer required for post-operative rehabilitation.
• Hip and knee replacement surgeries were previously on the Inpatient-only list of procedures that typically require patients to stay in a hospital overnight after surgery. These surgeries are now classified as outpatient, meaning the patient is expected to stay in the hospital for less than 24 hours.
• This gives patients more options in choosing the location, quality of care and the ability to save in the cost of their care.

Does Medicare Cover Knee Replacements

• byChristian Worstell

Original Medicare covers knee replacement surgery if it is considered to be medically necessary by your doctor. Both Medicare Part A and Medicare Part B may each cover different aspects of the procedure.

Medicare Advantage plans can also cover knee replacements. Many Medicare Advantage plans also cover benefits such as bathroom grab bars in your home and home meal delivery when you return home from an inpatient hospital stay.

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Am I A Candidate For Outpatient Joint Replacement

• Patient safety is the primary driver as to where surgery can be done. There are many contributing factors if a person can qualify as an outpatient joint patient.
• Single health factor concerns such as having diabetes or being overweight are not an automatic disqualifier.
• You can schedule an appointment online to see if you are a candidate.

Of Interest To Patients

For patients, what this change means is that patients will have more choice, will likely not pay more for that choice, and may face lower risk of hospital-acquired infections in the ASC setting, and notice more nursing attention in the ASC setting because there are fewer cases ongoing simultaneously as compared with the hospital setting. Their patient experience in the ASC is often much more enjoyable than in the hospital but previously they didnt have the choice to find out if they were a Medicare beneficiary.

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Medicare Coverage For Parts A And B

At present, Original Medicare Parts A and B pay for certain costs of knee replacement surgery provided the procedure is deemed medically necessary by the doctor. Part A would cover the expense of the hospital stay while Part B would cover out-patient and recovery services mandated by the physician.

Patients would have to pay Part B deductible and 20% of the co-insurance fees.

Medicare Part C would provide the same coverage as Medicare Part A and B and additional coverage for certain services. If you anticipate knee replacement surgery in the future, can explore Part C plans for better coverage.

Antibiotics, anticoagulants, and painkillers prescribed by the doctor following knee surgery would be covered by Medicare Part Ds prescription drug program or Medicare Advantage Prescription Drug policy.

Patients should check the costs of the procedure and the extensive aftercare that involves pain medications and physical therapy.

What To Know About Medicare And Knee Replacement Surgery

• Are There Other Medicare Benefits to Help Pay for Knee Replacements?

• A knee replacement, also known as an arthroplasty or total knee replacement, is a surgical procedure that helps reduce pain, improve mobility, and more for those with knee issues that have not seen relief through other methods.

• Original Medicare covers most of the costs of total knee replacements if it is deemed as a medical necessity. Costs will depend on whether the procedure is an inpatient surgery or performed in an outpatient setting.

• Medicare Advantage plans also will cover most of the costs of a knee replacement procedure.

• Medicare supplement insurance plans may also help drive knee surgery costs lower.

In the event a Medicare beneficiary needs knee replacement surgery, they may be wondering about how Medicare coverage works with this type of procedure. In short, Medicare covers some of the costs associated with knee replacement surgery, so long as the patients doctor declares the procedure to be medically necessary.

Ones exact Medicare plan, be it an Original Medicare plan, a Medicare Advantage plan, or otherwise will dictate the patients financial obligations further. This resource will explain everything that needs to be understood about Medicare and knee replacement surgery.

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Additional Knee Replacement Costs

Some additions to your living space can be made to ensure your comfort during recovery. These include toilet seat risers, safety bars, a shower bench, and even a modified first-floor living area to eliminate the need for stairs. You may be able to find affordable options on second-hand marketplaces such as Mercari and Ebay, or find discounts through cash-back apps such as Ibotta.

For patients with insurance, physical therapy costs are often covered. Usually patients will have to complete several weeks of physical therapy sessions following a knee replacement. Its always advisable to enter this stage of your recovery with an open mind and a positive attitude: after all, your recovery depends on you, and the mobility that you regain is directly related to the effort you put into your rehab.

Finally, depending on your lifestyle, your knee replacement device may need to be replaced later in life. The lifespan of current knee replacements can range from 10 to 15 years, to even longer. Remember to always notify your doctor if you experience uncharacteristic discomfort or limited mobility, as it these may be indicators of a complication with your knee replacement.

Knee replacement complications can include infection , complications from anesthesia , and other issues.

All material on this page is for informational purposes only and should not be construed as medical advice. Always consult your physician or pharmacist regarding medications or medical procedures.