Saturday, March 25, 2023

Out-of-pocket Cost For Medicare Hip Replacement

Hip Or Knee Replacements Under Medicare Advantage

Medicare Hip Replacement Cost?

Medicare Advantage plans are sold by private insurers and are required to cover everything that Original Medicare does, so your plan will cover at least what Medicare Part A and Part B cover.

But Medicare Advantage plans may also provide benefits that Original Medicare does not cover. These may include nonemergency transportation to doctor appointments or other medical visits associated with your joint replacement.

Some Medicare Advantage plans may also cover meal delivery services while you are at home recuperating from the surgery.

Why Are Hip Replacement Surgeries So Expensive

Even the low end of hip replacement surgery pricing can give a person massive sticker shock. There are a lot of items that add to the total cost of surgery, like:

  • Diagnostic testing, like blood work and X-rays

  • Use of the surgery operating room, which has a per-hour or per-procedure cost

  • Surgical assistants who help in the operating room

  • Medicinal or biological support for the surgery, like anesthesia, IV, blood, or plasma

  • The cost of the prosthesis used for surgery

  • The surgeons fee

  • Cost of the recovery room and your hospital stay

  • Skilled nursing facility charges if you require extensive care after surgery

  • Part-time nursing care during your recovery at home

This is just a brief list that covers some of the costs associated with hip replacement surgery and shows why the final bill is so high. Each line item will likely have different coverage depending on your insurer, which is why final costs can vary so much.

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Does Medicare Cover Gel Injections For Hip Pain

Injections of hyaluronic acid, a gel-like substance, receive Medicare coverage for the treatment of knee osteoarthritis when medically necessary. Yet, hyaluronic acid/sodium hyaluronate injections dont have FDA approval for use in hips or other joints.

There isnt sufficient evidence for effective treatment of hip osteoarthritis nor temporomandibular joint osteoarthritis or disc displacement. Thus, it is not a practical, long-term solution for hip joint pain.

Understanding The Hip Replacement Procedure

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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.

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How Much Will A Hip Replacement Cost Me As A Private Patient

If you choose to have your hip replacement carried out through the private system, data from the Medibank Surgical Variance Report 2017: Orthopaedic Surgery showed that the median out-of-pocket cost for a hip replacement was $141, but the average out-of-pocket fee charged by a surgeon was $2,054 across the two years to July 2016.

Does Medicare Pay For Hip Replacement Surgery

Hip replacement surgery will fall under Part B. Part B covers 80% of your medical costs. Youll be responsible for the remaining 20%, as well as other cost-sharing. If you have a Medigap plan the 20% coinsurance will be billed to them.

Depending on what letter plan you have, you may even have all other cost-sharing covered. Meaning, youll pay zero for your hip replacement surgery.

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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

  • Part A covers inpatient surgeries and hospital stays.
  • Part B covers outpatient procedures.
  • 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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    Do Medicare Advantage Plans Cover Knee And Hip Replacement Surgeries

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    Part C plans must cover at least as good as Medicare, which means you can expect the Medicare Advantage plan to cover your medically necessary knee or hip replacement surgery.

    If you have a Part C insurance plan, contact the plan administrator to understand your costs for surgery. One beneficial thing about Medicare Advantage plans is the maximum out-of-pocket expense. This protects you from spending more than a specific amount on your covered medical services.

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    Hip Replacement Surgery Cost

    Hip replacement surgery costs can be staggering, ranging from $30,000 to $100,000 or more, according to the American Association of Hip and Knee Surgeons. The average cost, however, is around $40,000.

    To know the exact cost of your surgery, talk with your doctor or contact Medicare. However, in most cases, what you pay also depends on your deductibles and the plan you have for coverage. Costs can also vary on your provider and facility where you receive care.

    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.

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    What To Know About Medicare And Knee Replacement Surgery

    • A knee replacement, also known as an arthroplasty or total knee replacement, is a surgical procedure that helps reduce pain, improve mobility, and more for those with knee issues that have not seen relief through other methods.

    • Original Medicare covers most of the costs of total knee replacements if it is deemed as a medical necessity. Costs will depend on whether the procedure is an inpatient surgery or performed in an outpatient setting.

    • Medicare Advantage plans also will cover most of the costs of a knee replacement procedure.

    • Medicare supplement insurance plans may also help drive knee surgery costs lower.

    In the event a Medicare beneficiary needs knee replacement surgery, they may be wondering about how Medicare coverage works with this type of procedure. In short, Medicare covers some of the costs associated with knee replacement surgery, so long as the patients doctor declares the procedure to be medically necessary.

    Ones exact Medicare plan, be it an Original Medicare plan, a Medicare Advantage plan, or otherwise will dictate the patients financial obligations further. This resource will explain everything that needs to be understood about Medicare and knee replacement surgery.

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    How Much Will Medicare Pay For Total Knee Replacement

    Hip Replacement Surgery Cost in Ludhiana, Hip Replacement Surgery in ...

    If its an inpatient surgery, Medicare will cover most of the cost. Youll be responsible for the Part A deductible, as well as additional cost-sharing in the form of coinsurance. If its an outpatient surgery, Medicare will cover 80% of the cost.

    Youll be responsible for the Part B deductible and 20% of the cost. Any prescriptions given at the hospital will also be covered under Part B. Any prescriptions that youre prescribed to take at home wont have coverage unless you have a stand-alone Part D plan. Or, if you have an Advantage plan that covered prescriptions.

    If you have a Medigap plan, depending on the letter plan you enrolled in, you could have zero out of pocket costs for total knee replacement surgery. If you have a Medicare Advantage plan, youll have to check with the carrier you enrolled with to determine what youll have to pay out of pocket.

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    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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    Do Medigap Plans Cover Hip Replacement Surgery

    MedSupp/Medigap, are Medicare supplement plans that fill in the gaps of Original Medicare. These plans are in addition to Original Medicare. As such, Medicare beneficiaries should expect their Medicare plan to still cover 80 percent of hip replacement costs, with their financial responsibility being 20 percent.

    As well, Medigap policies may reduce out-of-pocket costs depending on the specific plan and the insurance company.

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    Do You Have More Questions About Medicare Coverage Of Hip Replacements

    If youd like some help figuring out which Medicare plan option may fit your needs, feel free to contact me.

    • To schedule a phone call with me or have me email you Medicare plan options, click either of the links below.
    • To compare Medicare plan options yourself, use the Compare Plans buttons on this page.

    Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the Federal Medicare program.

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    Becoming eligible for Medicare can be daunting. But dont worry, were here to help you understand Medicare in 15 minutes or less.

    How Much Will A Hip Replacement Cost Me As A Public Patient

    Top 3 Mistakes After Total Hip Replacement

    The Medicare Benefits Schedule lists a range of hip replacement procedures which Medicare will provide a 75% benefit for, ranging from a basic partial arthroplasty through to a total hip replacement requiring bone grafts for both the pelvis and femur. The listed fees for these services range from $776.80 to $2,524.30, and the benefit provided ranges from $582.60 to $1,893.25. So if you choose to have your hip replacement carried out through the public system, you could incur an out-of-pocket cost between $194.20 and $631.05. Keep in mind, however, that surgeons and other medical practitioners are allowed to set and charge their own fees, which may end up exceeding the fee listed in the MBS.

    While having your hip replaced through the public system could potentially see you pay less in out-of-pocket costs than going through the private system, waiting list times for procedures can be significant. Data from the Australian Institute of Health and Welfare showed that in the 2018-19 period, the median wait time nationally for orthopaedic surgery was 77 days.

    Conversely, undergoing a hip replacement as a private patient will generally involve a shorter wait, but a potentially larger out-of-pocket cost.

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    How Much Does Medicare Pay For The Surgery

    The American Association of Hip and Knee Surgeons reports that the price of hip replacement surgery in the U.S. can be $30,000112,000. The hip implant costs about $3,00010,000, and the overall cost also includes staff and surgeon fees. The average surgeon reimbursement from Medicare for this surgery is $1,3751,450, according to the AAHKS.

    Generally, the amount that a person with Medicare pays depends on whether they have met deductibles and premiums. A doctor can give more specific information about the cost to expect.

    The annual deductible for Medicare Part A is $1,484, and for Part B it is $203. Most people do not pay a premium for Part A, and for Part B, the standard monthly premium in 2021 is $148.50.

    Medicare part A usually pays 100% percent of the remaining costs after a person meets the deductibles and premium. Medicare Part B pays 80%. This leaves the person to pay the remaining 20% plus their deductibles and premium. A person can check whether they have met their deductibles here.

    What Tiers Of Health Insurance Cover Hip Replacements

    Joint replacements are only covered as a minimum requirement on Gold hospital policies, according to However, this clinical category may also be included as an optional level of cover on Silver and Bronze policies. Where that is the case, the policy becomes a Silver Plus or Bronze Plus policy as the provider is offering cover beyond the minimum requirements of those tiers. Providers also have the option of including cover for joint replacements on their Basic hospital policies but on a restricted basis. According to, this means the policyholder would be partially covered for hospital costs as a private patient in a public hospital but may incur significant expenses in a private room or private hospital. It recommends checking with your insurer and hospital for details of what your policy will and will not cover.

    Remember that while cover for joint replacements may be covered on a private health insurance hospital policy, excesses, cover limits, and maximum payable benefits may vary significantly by policy and product tier. Its important to read the policy documents carefully and compare policies to help ensure youre getting a level of cover that is suitable for your situation.

    This article was co-written by James Hurwood.

    Main image source: Denis Simonov .

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    Medicare Part D And Hip Or Knee Replacements

    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

    Do Different Surgeons Charge Different Amounts For Hip Replacements

    Affordable Hip Arthroplasty, Resurfacing &  Total Hip Replacement Surgery

    The Medibank report found that the average total cost of a hip replacement ranged between $19,439 and $42,007 , and that some surgeons charged out-of-pocket costs as high as $5,567 for a hip replacement.

    The report also found that just over a third of surgeons charged no out-of-pocket fees for orthopaedic operations, but that when it came to hip replacement surgeries specifically, 42% of patients paid an out-of-pocket cost for their surgeon.

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    Office Of Health Care Statistics

    According to the Centers for Medicare and Medicaid Services, hips and knees are the two most commonly replaced joints. Both of these surgeries are done to reduce patient pain and increase mobility. Although it is most common for seniors to require hip and knee replacements, other age groups may also need this type of surgery.

    In this DataByte, we examine the prevalence of hip and knee surgeries in Utah over the past three years by various patient demographics. Additionally, we look at the normal/average cost range for these surgeries and compare Utah readmission rates with the national average. Any noticeable trends or differences between years are identified.

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