Do You Have More Questions About Medicare Coverage Of Hip Replacements
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Does Medicare Cover Hip Replacements
Hip replacement surgery, or arthroplasty, can improve mobility when other treatments, such as medication, physical therapy, and walking aids have not been effective in reducing pain and increasing the functionality of the joint. Arthroplasty is performed over 100,000 times each year and has a 90% success rate. Many seniors who need hip replacement surgery are understandably concerned about the medical expenses they may incur before, during, and after the surgery. The surgery can cost between $30,000 and $40,000, but Medicare can help cover some of the costs.
Why You May Need Hip Replacement Surgery
There are several conditions that can wear down the hip joint including, but not limited to:
- Avascular necrosis
- Bone tumors
Hip replacement surgery can restore the joint and its wide range of motion. Based on physician recommendations, your overall health, and your unique condition, the surgery may use cemented or uncemented prostheses to bond new parts of the joint to the healthy bone after diseased cartilage and bone tissue is removed. Recovery can take between 3 and 6 months but most patients report good results from the surgery.
How Medicare Can Help
According to the Centers for Medicare & Medicaid Services , Medicare will help cover the costs of hip replacement surgery when a patients symptoms have not responded to other treatments and a determination has been reached that major joint replacement is reasonable and medically necessary.
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Does Medicare Cover Hip Replacement And Associated Costs
- Hip replacement involves replacing the hip with artificial parts. Does Medicare cover hip replacement? Learn the answer to this question and more in this article.
Medicare does cover hip replacement as long as a physician confirms the procedure is reasonable and medically necessary and the beneficiary’s symptoms haven’t improved sufficiently through other treatment methods. While Medicare covers the costs of this procedure, the beneficiary may still be responsible to pay some of the costs.
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Understanding Medicare Surgery Coverage
Medicare surgery coverage can be confusing and challenging to understand.
Its difficult to determine exactly how much youll owe out-of-pocket because so many factors influence surgery cost.
Two Parts of Medicare Cover Surgery
Your Medicare coverage and out-of-pocket costs are different for inpatient and outpatient surgeries.
It is important to understand that you can receive care in a hospital and still be considered an outpatient.
Factors That Impact Your Surgery Cost with Medicare
- Whether the surgery is considered inpatient or outpatient.
- Where the surgery takes place.
- What part of the country you live in.
- How many doctors perform your surgery.
- If you have any supplement insurance, such as Medicaid or a Medigap policy.
- If youve already met your Part A or Part B deductibles.
- If treatment includes more than one procedure or if complications arise after surgery.
Surgery is one of several treatments covered under Medicare. A procedure must be considered medically necessary to qualify for coverage. This means the surgery diagnoses or treats an illness, injury, condition, disease or its symptoms.
To keep your costs low, make sure the doctor performing your surgery accepts Medicare assignment. This means the doctor agrees to accept the Medicare-approved cost for the procedure and wont bill you anything besides a copayment or coinsurance fee.
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Using This Guide Whats Covered
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To see how this surgery is done, view our animation below. For personal insights, see our patient experience videos in which HCF members talk frankly about their preparation, surgery and recovery.
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Medical Necessity Is The Main Qualifier When Determining Whether A Service Is Covered By Medicare
As long as the surgery is deemed medically necessary by your doctor, hip replacement surgery is usually covered by Medicare.
According to the Agency for Healthcare Research and Quality, more than 450,000 total hip replacements are performed each year in the U.S. More than half of those are for patients ages 65 and older.
Hip replacement surgery, or arthroplasty, removes or replaces your hip with an artificial joint, typically due to damage from arthritis or an injury. After a hip replacement, patients can usually walk easier, with less pain, and lead a healthier life.
Typically, your surgery will be covered by either Medicare Part A or Part B. Part D prescription drug coverage will also provide coverage for prescription drugs you may need after surgery.
Even though Medicare covers hip replacements, you must meet certain eligibility requirements and you may still have out-of-pocket costs. Read to understand Medicares coverage of hip replacement surgery, the cost of a hip replacement, and what the surgery involves for you.
Medicare Part D Prescription Drug Plans
Medicare Part D prescription drug plans are sold by private insurers. Since Medicare Part A only covers medications you receive while in the hospital, a Part D plan can help cover the costs of prescription medicines you may need after your knee or hip replacement.
Examples of Joint Replacement Medications Covered by Medicare Part D Plans
- Antibiotics to prevent or treat infection
- Anticoagulants such as warfarin
- Anti-inflammatory drugs
- Pain medicine such as NSAIDs and acetaminophen
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Costs Without Insurance Coverage
If your health plan does not cover hip replacement surgery or you do not have insurance coverage, you should discuss the costs during the initial consultation with your orthopedic surgeon. Hip replacement costs can vary from one practice to another and even from one patient to another depending on several factors.
The skill and experience of the operating surgeon, the kind of facilities and services they are able to provide, and the quality of the hospital or surgery center where the procedure is performed will make a difference to the overall costs. Make sure that while choosing an orthopedic surgeon, you do not automatically go with the one that offers the lowest cost.
Carefully consider the surgeons expertise, experience and whether they are board certified in orthopedic surgery. These aspects will make a critical difference to your final results. Board certified orthopedic surgeons Dr. Thomas and Dr. Bigler receive patients from Las Vegas, Nevada as well as greater Pahrump, Bullhead City, Lake Havasu, and Mesquite, NV for hip replacement surgery.
What Does Medicare Cover With A Hip Or Knee Replacement
Original Medicare Medicare Part A and Part B cover a wide variety of costs associated with hip and knee replacement surgery, also called lower extremity joint replacement or LEJR.
A Medicare Part D plan can help cover prescription drugs related to your hip or knee replacement surgery, while a Medicare Supplement plan helps cover the out-of-pocket costs not covered by Original Medicare.
Medicare Advantage plans must cover what Original Medicare does, but may include additional benefits.
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How Many Cortisone Shots Will Medicare Cover
Beneficiaries needing cortisone shots may have coverage for three cortisone shots annually. Repetitive injections may cause damage to the body over time.
Therefore, many orthopedic surgeons suggest such a low number for each patient per year. Part B pays for the administration of any cortisone injections if a healthcare provider administers the drug.
What Can You Expect To Pay For An Approved Inpatient Surgery
Medicare Part A generally covers much of the cost related to your inpatient surgery and hospital stay. You may be responsible for a Medicare Part A deductible for each benefit period. Medicare defines a benefit period as beginning the day youre admitted as an inpatient in a hospital or skilled nursing facility and ending when you have not received any inpatient hospital or SNF care for 60 days in a row. You pay this inpatient hospital deductible amount for each benefit period.
The amount you may pay for inpatient surgery can also depend on your recovery time. You wont typically pay a Medicare Part A coinsurance amount if your inpatient stay lasts between one and 60 days. However, if you spend more time in the hospital for inpatient surgery, you have to pay a coinsurance amount.
- You will pay $371 per day per benefit period for days 61 to 90.
- You will be liable for $742 per benefit period for every lifetime reserve day you spend in the hospital beyond 90 days.
- If you are still in the hospital after exhausting your lifetime reserve days, Medicare Part A generally will not continue coverage for your hospital expenses.
Medicare Part B usually pays 80 percent of the Medicare-approved amount for doctors services billed separately from the hospitals charges for inpatient surgery. You are responsible for 20% after you have met the Part B annual deductible .
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Understanding The Hip Replacement Procedure
Hip arthroplasty, also known as total hip replacement, is a common orthopedic procedure. During the surgery, your damaged bones and some soft tissue are removed.
The hip joint is replaced with an implant, which can be ceramic, plastic, or metal.
In a traditional replacement, a 10-12 inch incision is made on the side of the hip. In less-invasive procedures, the incision may only be three to six inches.
Some people may not be eligible for a minimally invasive procedure. Be sure to ask your doctor if you arent sure what your procedure will be like.
Does Medicare Cover Hip Replacement
Medicare typically covers hip replacement surgery after a doctor confirms that it is medically necessary.
Hip replacement surgery can help with mobility and maintaining a healthy lifestyle. Surgeons complete more than 400,000 of these procedures each year in the United States.
In this article, we describe which Medicare plans cover hip replacement surgery, including specifics about the coverage, eligibility, and costs. We then describe what the surgery entails.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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How Much Does Hip Replacement Cost
The average cost of hip replacement surgery varies dramatically, but estimates often range in the $20,000 to $40,000 range. Bupa, for example, calculated an average surgery cost of $31,820.
The Medicare Benefits Scheme fee for hip replacement as of May 2021 is $1,359.00. Individual costs do differ, however. The below chart shows the different benefit amounts paid by insurers on average for a hip replacement doctor’s fee.
- Ahm: $2,000.75
There are a number of things you can do to work out your own estimate:
- Ask if your surgeon is on your private health insurer’s preferred list to help find the most affordable option.
- Ask for their extras cost as things like an anaesthetist can cost a lot.
- Make sure there are no hidden out-of-pocket expenses like X-rays.
- Ask for the Medicare code.
- Find out your doctor’s estimated rebate.
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Will Medicare Help Pay For A Knee Replacement
Medicare Part A and Medicare Part B each cover a different aspect of joint replacement surgery. Medicare Part C will cover knee replacement, including both knees at once, only if your doctor considers it necessary.
Medicare Part D prescription drug program will cover the cost of painkillers, antibiotics, and anticoagulants required for the surgery.
How Much Do Hip Replacements Cost
According to the business magazine Forbes in 2015, the average cost for a hip replacement procedure is $30,124, including hospitalization, surgery, and rehabilitation. Hip replacement cost can vary by location, notes Forbes. Hip replacement surgery can be as little as $16,000 in Alabama and as much as $60,000 in New York. Keep in mind this is total cost, not out-of-pocket cost for a hip replacement patient who has Medicare.
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What Is An Inpatient Surgery
Inpatient surgery refers to surgery performed in the hospital after a doctor has admitted you as an inpatient. Your doctor may order an inpatient surgery during a hospital stay or may schedule surgery in advance of your hospital admission.
It is important to understand that you can be getting care in a hospital and still be an outpatient, not an inpatient. Your Medicare coverage and out-of-pocket costs are different for outpatient and inpatient surgery.
Medicare Coverage For Inpatient Rehabilitation
Medicare Part A covers medically necessary inpatient rehab care, which can help when youre recovering from serious injuries, surgery or an illness. Inpatient rehab care may be provided in of the following facilities:
- An inpatient rehabilitation facility
- Acute care rehabilitation center
- Rehabilitation hospital
For inpatient rehab care to be covered, your doctor needs to affirm the following are true for your medical condition:
1. It requires intensive rehab
2. It needs continued medical supervision
3. It needs coordinated care from your doctors and therapists working together
Medicare will cover your rehab services , a semi-private room, your meals, nursing services, medications and other hospital services and supplies received during your stay. Medicare wont cover private duty nursing, a phone or TV, personal items or a private room .
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Does Medicare Pay For Rehab After Hip Surgery
Many hip surgery patients are discharged from the hospital before theyre ready to live independently at home. Skilled nursing facilities like Bella Vista Health Center in San Diego provide a safe and comfortable place for patients to transition back to independent living. With access to a range of healthcare providers and rehabilitative services, residents are empowered to participate in their recovery while receiving the care they need to restore strength and functioning and get back to their personal best.
At Bella Vista Health Center, we often field calls from patients who have recently undergone or are preparing to undergo hip surgery, and who want to know if Medicare pays for rehab after hip surgery. The short answer is yes. But that wasnt the case just two years ago. Prior to 2020, total hip surgery was on a list of procedures that only qualify for inpatient medicare coverage, not rehabilitation coverage. In 2020, however, total hip surgery was removed from that list, making it available now for rehabilitation coverage through Medicare. There are, however, some stipulations, which well cover in the longer answer below. Read on for more information about Medicare and hip surgery rehab.
Medicare and inpatient rehabilitation
If youre enrolled in Medicare Part A, youll be happy to know that it covers medically necessary inpatient rehab care as long as your condition and the facility meet the qualifying requirements.