Does Medicare Cover Hip Replacement?

When Medicare Considers Hip Replacement Medically Necessary

Medicare does not cover surgery simply because it is requested. Your surgeon documents why hip replacement is appropriate for you. Medicare coverage policies generally look for:

• Advanced joint disease confirmed by imaging, such as X-rays showing significant joint space narrowing.
• Pain or loss of function that limits daily activities like walking, climbing stairs, or putting on shoes.
• Nonsurgical treatment that has not provided enough relief, when appropriate. This may include medication, activity changes, physical therapy, or injections, often for several months.

Your consultation is where these details are reviewed and recorded. If you are unsure whether you have reached that point, read how to tell when hip arthritis warrants surgery.

Which Parts of Medicare Cover Hip Replacement?

Hip replacement touches several parts of Medicare:

• Part A (hospital insurance) generally covers your stay if you are admitted as a hospital inpatient.
• Part B (medical insurance) generally covers your surgeon’s services, outpatient surgery, physical therapy, and medical equipment like a walker.
• Part D (prescription drug coverage) may cover medications you take at home during recovery.
• Medicare Supplement (Medigap) policies may help pay deductibles and coinsurance left after Original Medicare pays its share.
• Medicare Advantage (Part C) plans must cover everything Original Medicare covers, but they often use provider networks, referral rules, and prior authorization. They also set an annual limit on out-of-pocket costs for covered services.

Inpatient, Outpatient, or Same-Day: Why It Matters

Hip replacement was once covered by Medicare only as an inpatient hospital procedure. Since 2020, Medicare can also pay for it in a hospital outpatient setting, and since 2021, at approved ambulatory surgery centers. Where your surgery takes place depends on your health, home support, and surgical plan. Some appropriate candidates may go home the same day.

The setting affects your costs. Inpatient care generally falls under Part A, while outpatient care falls under Part B, each with different cost sharing. Time spent under observation in a hospital counts as outpatient.

It can also affect recovery coverage. Original Medicare generally covers skilled nursing facility care only after at least 3 consecutive days as a hospital inpatient, not counting the discharge day. Many patients recover at home instead, often with outpatient or home health physical therapy. See the hip replacement recovery timeline for what that typically involves.

Are Robotic-Assisted and Direct Anterior Hip Replacement Covered?

Medicare coverage decisions focus on whether hip replacement is medically necessary. Robotic assistance and the surgical approach describe how the procedure is performed.

Dr. Avino performs robotic-assisted hip replacements using Mako technology, and 100% of his current primary total hip replacements are performed via the direct anterior approach. Mako planning often uses a CT scan to build a 3D model of your hip. If you have a Medicare Advantage plan, ask whether that imaging needs separate approval.

What You May Pay

With Original Medicare, an inpatient stay generally involves the Part A deductible for that benefit period. Surgeon fees and outpatient services generally involve the Part B deductible, then coinsurance (typically 20% of the Medicare-approved amount). A Medigap policy may cover some or all of those costs.

With Medicare Advantage, you typically pay copays or coinsurance set by your plan, up to its annual out-of-pocket maximum. Using in-network surgeons and facilities usually keeps costs lower.

How to Confirm Your Coverage

Call the number on your Medicare or plan card and ask:

• Is my surgeon in network, and do I need a referral?
• Does hip replacement require prior authorization, and who submits it?
• Are the hospital or surgery center and anesthesia in network?
• How are physical therapy, medical equipment, and prescriptions covered?
• What will my total out-of-pocket cost likely be?

Write down the date, the representative’s name, and a reference number for each call.

Timing tip: If you are planning hip replacement next year, review your plan during Medicare Open Enrollment, October 15 to December 7. You can switch between Original Medicare and Medicare Advantage or change plans, with changes taking effect January 1. People already in Medicare Advantage also have a second window, January 1 to March 31.

This article is for general information only and is not insurance advice. Coverage varies by individual plan. Please confirm your benefits directly with your Medicare plan.