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If you have Medicare and need a knee replacement, they’ll likely cover at least a portion of your procedure. However, there are a few things to keep in mind before moving forward with your surgery.

Thomas Calton, MD, leads the team at Utah Orthopedics, a world-class medical facility in Ogden, Utah. He’s been practicing orthopedic surgery for more than 30 years and specializes in joint replacements involving the hip and knee.

If you’re considering a knee replacement, here’s what you need to know about Medicare coverage.

Qualifying for coverage

In general, in order for Medicare to cover knee replacement surgery, the surgery needs to be deemed “medically necessary” by your doctor. In making a determination, your doctor will consider a number of things, including the following:

  • What is the extent of joint damage or disease?
  • Is the pain severe or persistent, even at rest?
  • Does the pain respond to conservative treatments?
  • Is there reduced mobility and/or reduced quality of life?

If a knee replacement isn’t deemed medically necessary, Medicare may cover alternative treatments, such as nerve therapy, unloader knee braces, and viscosupplementation, which involves injecting a lubricating fluid into your knee joint.

There’s no age limit for getting a knee replaced using Medicare, but replacements usually occur in people ages 50-80. To qualify for Medicare, you generally need to be age 65 or older or on disability for at least two years.

Types of coverage

Medicare is broken into three parts, and they cover specific services. And, while Medicare pays for a lot, it doesn’t cover all healthcare costs.

Medicare Part A (hospital insurance)

This portion of Medicare deals with costs associated with inpatient procedures, including hospital stays, hospice care, nursing facilities, and some home health care. As a result, Medicare often covers most of the cost of an inpatient knee replacement. But, you pay your Part A deductible and any costs associated with your coinsurance.

Medicare Part B (medical insurance)

Part B covers other medical services, such as outpatient procedures, medical supplies, and preventive care. And, as of January 1, 2020, that also includes outpatient knee replacement surgeries. However, Medicare Part B only covers 80% of the cost of your procedure, so you pay your Part B deductible along with 20% of the costs associated with your surgery.

Medicare Part D (prescription drug coverage)

Medicare also offers prescription drug coverage, but you have to join an approved plan to participate. For example, when you have knee replacement surgery, prescriptions you receive at the hospital get covered under your Part B plan. However, prescriptions you take home don’t fall under this coverage. Insead, this would fall under Part D or a Medicare Advantage Plan that includes prescriptions.

Medigap (supplemental insurance)

As the name implies, this supplemental form of insurance “fills the gaps” in Medicare. If you have a policy like this sold by a private company, you could have zero out-of-pocket costs associated with your surgery.

How to get started

Fortunately, you don’t have to navigate these unknown waters alone. The easiest way to determine your Medicare eligibility is by scheduling an appointment with Dr. Calton for a thorough evaluation. During this assessment, he can also recommend whether you should undergo an inpatient or outpatient procedure.

After gaining these insights, Dr. Calton can guide you through the next steps, so you can know exactly what to expect when having knee replacement surgery using Medicare.

To learn more about knee replacement surgery and Medicare, book an appointment over the phone with Utah Orthopedics today.

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