Does Medicare Cover Hip Replacement?

Medicare covers hip replacement surgery when it is deemed medically necessary, but costs can vary significantly. Beneficiaries must navigate important limits and potential out-of-pocket expenses.

Understanding Medicare’s coverage for hip replacement surgery is crucial for beneficiaries facing this significant procedure. While Medicare generally provides coverage for medically necessary surgeries, the rules are stricter than many expect, and costs can add up quickly, making it essential to know what to anticipate before moving forward.

Understanding Medicare Coverage for Hip Replacement Surgery

Medically Necessary Procedures Are Covered

Medicare covers hip replacement surgery when it is deemed medically necessary by a doctor. This coverage extends to various costs associated with the procedure, including doctor fees, hospital fees, and necessary follow-up care such as physical therapy, ensuring that beneficiaries receive comprehensive support throughout their treatment.

Specific Coverage Under Medicare Parts A and B

Medicare Part A plays a vital role in covering hospital costs for inpatient hip replacement surgery, while Part B covers outpatient procedures and related services. Additionally, durable medical equipment needed after surgery, such as canes or walkers, is also covered under Part B, providing essential support for recovery.

Rehabilitation and Follow-Up Care

Before surgery, Medicare may cover pre-surgery exams and tests when they are deemed medically necessary. Following the procedure, post-surgery rehabilitation services, including physical therapy, are also covered if necessary, ensuring that patients have access to the care they need to recover effectively.

Cost Implications for Medicare Beneficiaries

Understanding Out-of-Pocket Costs

Beneficiaries should be aware that they typically pay 20% of the Medicare-approved amount for Part B services after meeting the deductible. For inpatient hip replacement, the Part A deductible must be paid first, while outpatient procedures under Part B require payment of the Part B deductible and coinsurance.

Projected Costs for 2026

Looking ahead to 2026, the Part A inpatient hospital deductible is projected to increase to $1,736. Additionally, the standard Part B monthly premium is expected to be $202.90, with a deductible of $268, leading to estimated patient shares for a typical hip replacement ranging from $1,800 to $2,100.

Key Exceptions to Medicare Coverage

Understanding Coverage Limitations

While Medicare provides coverage for hip replacement, out-of-pocket costs may still apply, including deductibles and coinsurance. Furthermore, Medicare does not cover items deemed not medically necessary during recovery, emphasizing the importance of proper documentation of medical necessity to avoid denied coverage.

Criteria for Skilled Nursing Facility Coverage

To qualify for coverage of skilled nursing facility rehabilitation after hip replacement, beneficiaries must have a qualifying inpatient stay of at least three consecutive days. It’s important to note that days spent under observation do not count toward this requirement, which can affect access to necessary rehabilitation services.

Eligibility Requirements for Medicare Coverage

Confirming Medical Necessity

To receive Medicare coverage for hip replacement services, a doctor must confirm that the surgery is medically necessary. Enrollment in Medicare is also required, with common medical indications for coverage including severe osteoarthritis and fractures.

Recent Updates Affecting Medicare Coverage

Changes in Costs and Coverage

Recent updates indicate that cost-sharing amounts for hospital stays and outpatient services will increase in 2026. The 2026 Medicare & You handbook confirms that joint replacements, including hip replacements, remain covered by Medicare in both inpatient and outpatient settings, along with related rehabilitation care.

Essential Tips for Navigating Medicare Coverage

Planning for Hip Replacement Surgery

Before proceeding with hip replacement surgery, beneficiaries should confirm with their doctor that the procedure is medically necessary to ensure coverage. It’s also advisable to check specific Medicare plan details to understand coverage for hip replacement costs and discuss post-surgery needs with healthcare providers.

Utilizing Medicare Resources Effectively

Beneficiaries can utilize Medicare’s online tools to compare expected costs in different settings, which can help in planning for the surgery. Additionally, verifying current deductibles and premiums with Medicare or their plan can provide clarity on potential out-of-pocket expenses.

Navigating Medicare Coverage for Hip Replacement: Key Takeaways

Understanding Medicare’s coverage for hip replacement is essential for beneficiaries facing this significant procedure. While Medicare covers hip replacement when medically necessary, costs can vary, and beneficiaries should remain informed about updates and utilize available resources to manage their expenses effectively.