Medicare generally covers hip replacement surgery when a doctor determines the procedure is medically necessary to treat severe joint damage, typically from conditions like osteoarthritis. Coverage for the various components of a total hip replacement—from the hospital stay to post-surgical rehabilitation—is spread across Original Medicare (Part A and Part B). Understanding which part covers what service and the associated patient costs is important for anyone preparing for this common orthopedic procedure.
Inpatient Stay and Facility Costs
The primary coverage for the facility costs of a hip replacement performed in a hospital setting falls under Medicare Part A (Hospital Insurance). Part A covers the facility charges, including the operating room, a semi-private room, general nursing care, and any drugs administered during the inpatient stay. If the procedure is done on an inpatient basis, the beneficiary is responsible for a Part A deductible for each “benefit period.”
A benefit period begins the day a person is admitted as an inpatient to a hospital or skilled nursing facility and ends after they have been out for 60 consecutive days. For 2025, the Part A deductible is \$1,676. Once this is paid, Medicare covers the full cost for the first 60 days of a hospital stay. Since most hip replacement patients stay in the hospital for only one to three days, they typically do not incur any further inpatient coinsurance.
Since the facility costs are covered under Part A, this component does not include the surgeon’s fee or other professional services. These professional fees are covered separately under Part B.
Physician Services and Outpatient Needs
Medicare Part B, or Medical Insurance, covers the professional services rendered by doctors and other medical providers during the surgical process. This coverage includes the orthopedic surgeon’s fee, the anesthesiologist’s charges, and consultations both before and after the surgery. Part B also covers the facility fee if the hip replacement is performed in an outpatient surgical center.
The patient must first satisfy the annual Part B deductible, which is \$257 in 2025. After the deductible is met, Medicare pays 80% of the approved amount for these professional services. The beneficiary is responsible for the remaining 20% coinsurance, which applies to the fees for the surgeon, the anesthesiologist, and doctor visits.
Part B also covers Durable Medical Equipment (DME), which is frequently needed following a hip replacement. Medically necessary items like walkers, crutches, or a hospital bed are covered under this part. For approved DME, the 80/20 cost-sharing structure applies: Medicare pays 80% and the patient pays 20% of the approved amount.
Post-Surgical Rehabilitation and Recovery Care
Recovery often involves rehabilitation, which may include a stay in a Skilled Nursing Facility (SNF). Medicare Part A covers SNF care, but only if the beneficiary meets the requirement of a qualifying hospital stay. This historically requires at least a three-day, consecutive inpatient admission; time spent under “observation status” does not count.
If the qualifying stay requirement is met, Part A covers up to 100 days of SNF care per benefit period. The first 20 days of SNF care are covered at 100%, with no coinsurance. However, the patient must pay a daily coinsurance for days 21 through 100, which is \$209.50 per day in 2025.
Outpatient physical therapy (PT) and occupational therapy (OT) are essential for recovery and fall under Medicare Part B coverage. These services follow the standard Part B cost-sharing rules. Medicare covers 80% of the approved amount for medically necessary outpatient therapy, with the patient paying the 20% coinsurance after the Part B deductible is satisfied.
Understanding Medicare Advantage Coverage
Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. These plans must legally cover all services that Original Medicare (Parts A and B) covers, including hip replacement surgery. However, they manage this coverage differently, often replacing the Part A and Part B cost-sharing rules with their own structure.
These plans utilize provider networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). This means beneficiaries may need to use network hospitals and specialists. Unlike Original Medicare, Medicare Advantage plans frequently require prior authorization for procedures like hip replacement surgery and subsequent SNF stays.
Medicare Advantage plans also have different patient financial obligations, including varying co-pays, co-insurance amounts, and a maximum out-of-pocket (MOOP) limit. Once the MOOP limit is reached, the plan pays 100% of the covered services for the rest of the year. Beneficiaries should consult their specific plan documents to understand their exact costs and any network restrictions.