Orlando Harmon
Knee replacement surgery is a common but complex procedure. Medicare will cover knee replacement surgery costs if it is deemed medically necessary by a doctor. However, there are different types of knee replacement surgeries, and the coverage depends on whether the surgery is inpatient or outpatient and the type of Medicare plan. Inpatient procedures are covered by Medicare Part A, while outpatient procedures are covered by Medicare Part B. In both cases, Medicare covers 100% of the cost of covered services for the first 60 days, after which you'll need to pay coinsurance for each day of inpatient care and 20% coinsurance for Part B services. You will also have out-of-pocket costs, including deductibles, copays, and coinsurance, which vary based on your specific plan.
| Characteristics | Values |
|---|---|
| Medicare Part that covers inpatient knee replacement surgery | A |
| Medicare Part that covers outpatient knee replacement surgery | B |
| Medicare Part that covers all that Original Medicare covers | C (Medicare Advantage) |
| Cost covered by Medicare for inpatient knee replacement surgery | 100% for the first 60 days of inpatient admission per benefit period |
| Cost covered by Medicare for outpatient knee replacement surgery | 80% after the deductible is met |
| Cost to be paid by the patient for outpatient knee replacement surgery | 20% coinsurance |
| Cost to be paid by the patient for inpatient knee replacement surgery | Part A deductible of $1,676 per benefit period for days 1 to 60 in the hospital in 2025 |
| Cost to be paid by the patient for inpatient knee replacement surgery | Coinsurance for each day of inpatient care after the first 60 days |
| Cost to be paid by the patient for outpatient knee replacement surgery | Part B deductible ($240 in 2024) and 20% coinsurance for anesthesia services and the surgeon's fees |
| Cost to be paid by the patient for skilled nursing facility care after inpatient knee replacement surgery | No coinsurance for days 1 to 20 during the benefit period; a daily coinsurance amount is applied to days 21 and beyond |
| Cost to be paid by the patient for skilled nursing facility care after outpatient knee replacement surgery | May have to be paid out of pocket |
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What You'll Learn
Inpatient vs. outpatient surgery
Knee replacement surgery is one of the most common medical procedures, with 790,000 such surgeries performed each year in the United States. Medicare covers knee replacement surgery if it is medically necessary, and the specific plan chosen will determine the out-of-pocket costs.
Original Medicare (Parts A and B) may help pay some of the costs of knee replacement surgery. Medicare Part A, which is hospital insurance, will cover inpatient knee replacement surgery. For days 1 to 60 in the hospital, you will pay a Part A deductible of $1,676 per benefit period in 2025. If you recover at a skilled nursing facility, you won't pay any coinsurance for days 1 to 20 during your benefit period. Medicare also covers costs associated with your recovery, including physical therapy and equipment.
Medicare Advantage (Part C) must cover all that Original Medicare covers and may pay a portion of the costs depending on the type of surgery and the facility. You will have out-of-pocket costs, including deductibles, copays, and coinsurance.
Inpatient joint replacement procedures are open-surgery operations that require a hospital stay of at least one night, but more commonly several days for post-procedure follow-up. The extensive surgical incisions can limit your ability and may require a higher level of care than you would receive at home.
Outpatient joint replacement procedures are ambulatory, same-day surgeries that have become more common due to improved perioperative recovery protocols, value-based care, and bundled payment initiatives. Outpatient procedures are made possible by improvements in surgical instruments, approaches, and anesthesia, which minimize the impact on the body and reduce the need for medical observation. Smaller and more precise incisions result in reduced pain and less need for aggressive pain medications. Patients who undergo outpatient procedures also benefit from being in familiar surroundings, which can aid sleep and lead to faster recovery.
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Original Medicare vs. Medicare Advantage
Knee replacement surgery is one of the most common medical procedures in the United States, with 790,000 surgeries performed each year. Medicare covers knee replacement surgery if it is medically necessary, and this includes the costs associated with recovery, such as physical therapy and equipment.
Now, when it comes to choosing between Original Medicare and Medicare Advantage, there are a few key differences to consider. Firstly, Original Medicare (Parts A and B) allows you to use any doctor, whereas Medicare Advantage (also known as Part C) has limited networks of providers. With Original Medicare, you can use it anywhere in the US, whereas Advantage has geographic limits. Medicare Advantage plans may not pay for out-of-network providers, and your costs will be higher if you choose to use a doctor that isn't in their network.
In terms of coverage, both Original Medicare and Medicare Advantage must provide the same medical care by law. This includes inpatient hospital stays, skilled nursing care, home care, diagnostic tests, doctor visits, and outpatient surgery. However, it's important to note that neither covers medical care received abroad. Original Medicare does not include prescription drugs, routine dental, hearing, or vision care, whereas many Medicare Advantage plans do provide some coverage for these services.
Cost-wise, both options will likely result in some out-of-pocket expenses, but these will differ between the two. With Original Medicare, you will have deductibles, copays, and coinsurance to pay. Medicare Advantage plans will also have deductibles and copays, but these will vary depending on the specific plan chosen. Medicare Advantage premiums may be lower than those of Original Medicare, but other costs may be higher.
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Costs covered by Medicare
Medicare covers knee replacement surgery if it is deemed medically necessary. However, the specific costs covered by Medicare for knee replacement surgery depend on whether the procedure is performed as an inpatient or outpatient, and whether the individual has Original Medicare (Parts A and B) or Medicare Advantage (Part C).
For inpatient knee replacement surgery, Medicare Part A covers the surgery itself and the associated hospital costs. This includes the cost of the inpatient stay and the operating room. To have these costs covered by Medicare, the individual must first meet their Part A deductible, which was $1,676 per benefit period in 2025. A benefit period starts the day a person enters a hospital as an inpatient and lasts for 60 days. If an individual stays in the hospital for less than 60 days in each benefit period, no coinsurance applies. If an individual requires skilled nursing care after their inpatient stay, Medicare Part A will cover the first 20 days of their stay without any coinsurance for days 1 to 20 during their benefit period.
For outpatient knee replacement surgery, Medicare Part B provides coverage. After meeting the Part B deductible, which was $257 in 2025, Medicare Part B covers 80% of allowed charges, while the individual pays the remaining 20%. Outpatient rehab and other recovery services and equipment may be covered in full by Medicare Part B, or the individual may be expected to pay around 20% of allowed charges after meeting their deductible.
Original Medicare (Parts A and B) may also cover costs associated with recovery from knee replacement surgery, including physical therapy and medical equipment such as a continuous passive motion machine. Medicare Advantage (Part C) plans must cover everything that Original Medicare covers and may offer additional benefits. The specific out-of-pocket costs for individuals with Medicare Advantage plans depend on the chosen plan.
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Deductibles, copayments, and coinsurance
Medicare covers knee replacement surgery if it is deemed medically necessary. However, there are out-of-pocket expenses associated with the surgery, including deductibles, copayments, and coinsurance.
A deductible is an annual amount that a person must pay out of pocket before Medicare starts funding their treatments. For instance, the Medicare Part B deductible for 2025 is $257. After meeting this deductible, Medicare pays 80% of the allowed charges, while the patient pays the remaining 20% as coinsurance.
Coinsurance is the percentage of treatment costs that a patient must self-fund. For Medicare Part B, the coinsurance is typically 20%. This means that after paying the deductible, Medicare covers 80% of the costs, and the patient is responsible for the remaining 20%.
Copayment, or copay, is a fixed-dollar amount that a person with insurance pays when receiving certain treatments, usually for prescription drugs. For instance, Medicare Part D covers prescription drugs taken at home following knee replacement surgery, such as antibiotics, anticoagulants, or pain relief medications. Depending on the plan, the beneficiary may need to pay a copayment or coinsurance for these medications.
Medicare Advantage (Part C) plans combine the benefits of Original Medicare (Part A and Part B) and often include additional coverage, such as prescription drugs, dental, vision, and hearing services. Some plans may also offer extra benefits like transportation to medical appointments or gym memberships, beneficial during recovery.
Medicare Supplement (Medigap) Insurance plans help cover some of the out-of-pocket costs that Original Medicare doesn't fully cover, including deductibles, copayments, and coinsurance.
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Medically necessary procedures
Knee replacement surgery is a common but major procedure. Medicare will cover knee replacement surgery costs if it is deemed medically necessary by a doctor. The type of coverage you receive will depend on whether the surgery is inpatient or outpatient, and whether you have Original Medicare or Medicare Advantage (Part C).
If your knee surgery is an inpatient procedure, Medicare Part A will provide coverage. You will pay a Part A deductible of $1,676 per benefit period in 2025 for days 1 to 60 that you're in the hospital. If you recover at a skilled nursing facility, you won't have any coinsurance for the first 20 days during your benefit period. After that, you'll need to pay coinsurance for each day of inpatient care.
If you have outpatient surgery, Medicare Part B would provide coverage. Part B covers the surgeon's fees, pre-surgery consultations, post-operative care, and anesthesia services. Beneficiaries will be responsible for paying the Part B deductible (in 2024, this was $240) and a 20% coinsurance for these services after the deductible is met.
Medicare Advantage plans must cover all that Original Medicare covers, so your plan will cover knee replacement surgery. Your out-of-pocket costs will depend on the specific plan you choose.
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Frequently asked questions
Yes, Medicare covers knee replacement surgery if it is deemed medically necessary by a doctor. Depending on the type of surgery and the facility, Original Medicare or Medicare Advantage may pay a portion of the costs.
Out-of-pocket costs for knee replacement surgery with Medicare include deductibles, copays, and coinsurance. The amount you pay will depend on factors such as the type of surgery (inpatient or outpatient), where you live, and where you have the surgery.
To determine the exact costs of knee replacement surgery with Medicare, you can contact Medicare directly, speak to a licensed insurance agent, or use the Medicare website to search for a list of nationally covered items and services.
