Are you one of those people who has been suggested knee replacement (total knee arthroplasty) surgery by your orthopedic surgeon but are in a fix because you are not sure if Medicare will cover the surgery at your age?
As much as you want to get the surgery done and improve your quality of life, the lack of knowledge about Medicare coverage may be holding you back.
Medicare covers knee surgery along with a lot of other services. This article shares detailed information about the age eligibility for which
Medicare would cover knee replacement surgery costs, the excess charges you may face, and how they could be covered.
Medicare Age Limit for Knee Replacement in the United States
In the United States, Medicare is only available to those above the age of 65 years.
So naturally, a patient qualifies to be covered for knee replacement surgery under Medicare only after 65 years of age.
Medicare Part B
This part of Medicare has policies that provide almost complete coverage (around 80%) for patients (over 65 years) who need knee replacement surgery.
This surgery will always qualify as a medical necessity by the medical practitioner. You will, however, have to get the surgery done by only a doctor who is a registered Medicare-participating provider to get the benefits of the plan.
For the excess costs (rest of the 20%) not covered by Medicare, supplementary or private insurance plans are taken by most people. Parts F and G of these plans help cover all the remaining costs of knee surgery.
DME and Doctor visits
Doctor visits, durable medical equipment (DME), preventive care, outpatient services are all covered under Part B of Medicare.
Medicare will only pay for 150 consecutive days of hospital stay during your knee surgery. Any charges beyond this limit would need to be borne by you or through your supplementary health plans.
But since knee surgery hospital stays are rarely this long, they are fully covered by Medicare.
If for some reason, you do not want to stay at home after surgery or do not have a caregiver at home and are interested in going to a skilled nursing facility, Medicare will cover that too. However, it will cover just the first 100 consecutive days of your stay there.
Physical Therapy and Rehabilitation
Medicare will only cover a certain amount of the cost for physical therapy and rehabilitation. This cost and time will vary from state to state as per the Medicare policy in that state. After that time is over, you may have to go in for a review with your specialist to get it extended again.
All outpatient rehabilitation is covered under Medicare. All outpatient rehabilitation services fall under Medicare, part B. However, if you are unable to go to the rehabilitation center post the surgery, you could avail of the services at home.
So, in short, since in the United States, knee replacement surgery is an outpatient procedure, Medicare Part B will cover 80% of the total surgery costs for those aged 65 and above. The rest of the 20% can be covered by supplementary plans so that you pay nearly zero treatment costs out of your pocket.
What Is the Medicare Knee Replacement Age Limit in Canada?
Canadians of all age groups, men, women, and children, are covered by Medicare. Medicare takes care of all procedures deemed medically necessary by the physician.
Knee replacement surgeries are categorized as medically necessary by the specialist and thus, covered by Medicare.
- Everyone with a valid health card is covered by Medicare at all facilities which are registered with Medicare. Nearly 70% of the cost is borne by Medicare. The rest of the 30% is private spending. Most of the people cover the remaining 30% of the cost, via supplementary health insurance or insurance provided by their employer. Surgery costs vary from one province to another but the patient usually has no out-of-pocket spending costs in such cases.
- Hospital stay, food, and medical tests are all covered by Medicare for in-patients.
- Prescription drugs are given to the patient in the hospital are covered by Medicare.
- Physical therapy. Only physical therapy during a hospital stay is covered. All physical therapy after hospital discharge is not covered by Medicare unless mentioned by the specialist as necessary.
In summary, health care programs such as Medicare help make life-improvement surgeries accessible to patients at minimum or no costs. Patients are often unaware of what all is covered under Medicare and at what age.
This article would have cleared your queries regarding age-related Medicare coverage. If you still have any remaining doubts, it’s always better to speak to your concerned Medicare-registered orthopedic specialist or your health insurance provider.
Once this is sorted, you will naturally be stress-free about your surgery and just need to focus on your health and a speedy recovery.