A hip replacement, or total hip arthroplasty, is a common orthopedic procedure where a damaged hip joint is replaced with an artificial implant. Medicare generally covers this surgery when a physician determines it is medically necessary to relieve severe pain, restore function, and improve mobility due to conditions like severe osteoarthritis. Understanding how this coverage works is the first step toward managing the financial aspects of the procedure.
Original Medicare Coverage for the Procedure
Original Medicare splits the costs of a hip replacement into facility and professional services. Medicare Part A covers the inpatient care received in a hospital setting. This includes the semi-private room, meals, general nursing, and the use of the operating and recovery rooms. Part A coverage begins once a physician formally admits the patient to the hospital for the procedure.
Coverage is contingent on the procedure being medically necessary and meeting Medicare’s criteria for an inpatient stay. The artificial joint components are also covered under Part A as part of the hospital services. Medicare requires specific documentation, such as confirmation of severe degenerative joint disease, before approving the claim.
Medicare Part B addresses the professional fees associated with the hip replacement. This includes the services provided by the surgical team, such as the orthopedic surgeon, the assistant surgeon, and the anesthesiologist. Part B also covers various diagnostic tests and imaging, like X-rays and blood work, that are performed prior to the surgery in an outpatient setting.
Part B covers certain durable medical equipment (DME) needed for recovery outside the hospital. Items like walkers or crutches, which are medically necessary to aid mobility after the arthroplasty, fall under this coverage. The coverage for these items is subject to the standard Part B cost-sharing rules.
Patient Financial Responsibility
Even with Original Medicare coverage, the patient is responsible for several out-of-pocket expenses. For Part A hospital services, the patient must first pay the inpatient deductible, which applies per “benefit period.”
A benefit period begins the day a patient is admitted and ends after the patient has been out of the facility for 60 consecutive days. Since most hip replacements require a short hospital stay, the patient usually pays the deductible only once. If the stay exceeds 60 days, the patient becomes responsible for a daily coinsurance amount.
The patient’s financial responsibility for the Part B professional services begins with paying the annual Part B deductible. This deductible must be met before Medicare starts contributing to the cost of the surgeon’s fees, anesthesiology, and pre-operative tests. This deductible is a fixed annual amount, unlike the Part A deductible.
Once the Part B deductible is satisfied, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for all remaining Part B services. This 20% share applies to the surgeon’s bill, anesthesiologist’s bill, follow-up visits, and outpatient physical therapy.
Coverage for Post-Surgical Rehabilitation
Post-operative recovery often requires rehabilitation, which Medicare may cover in a skilled nursing facility (SNF). To be eligible for Part A coverage in a SNF, the patient must have had a qualifying inpatient hospital stay of at least three consecutive days before discharge. This stay must be documented as an inpatient admission.
Once the qualifying stay is met and the patient requires skilled care, Medicare Part A covers the first 20 days of the SNF stay entirely. Skilled care involves services like wound care or therapy that must be administered by trained professionals. For days 21 through 100 in the same benefit period, the patient is responsible for a daily coinsurance amount.
If the patient does not require or qualify for a SNF stay, or after the SNF coverage is exhausted, rehabilitation often continues with outpatient therapy. Outpatient physical therapy (PT) and occupational therapy (OT) are covered under Medicare Part B. These services are designed to help the patient regain range of motion, strength, and the ability to perform daily activities following the arthroplasty.
Coverage for all rehabilitation services is limited to skilled care deemed medically necessary to improve the patient’s condition. Medicare does not cover custodial care, which is non-skilled personal care like assistance with bathing or dressing, when that is the only care needed. The 20% Part B coinsurance applies to all approved outpatient therapy sessions after the annual deductible is met.
Role of Medicare Advantage Plans
Beneficiaries enrolled in a Medicare Advantage Plan (Part C) receive coverage through the private insurance company administering the plan. By law, these plans must cover all the same services as Original Medicare (Parts A and B), including the surgery and rehabilitation. However, the cost-sharing structure is typically different, often substituting fixed copayments for the Part A and Part B deductibles and coinsurance.
These private plans frequently require patients to receive care from providers within a specific network, such as an HMO or PPO. Prior authorization is also a common requirement before the surgery or a subsequent SNF stay can be approved. Failure to follow these specific plan rules can lead to reduced coverage or denial of payment.
A key difference from Original Medicare is that Part C plans must include an annual maximum out-of-pocket limit. Once this cap is reached, the plan pays 100% of covered services for the remainder of the year. Patients should contact their plan administrator to confirm specific copay amounts, network participation, and the exact out-of-pocket maximum before scheduling the hip replacement.