Does Medicare Cover Knee Replacement Therapy?

Flexibility and mobility are incredibly important when it comes to your quality-of-life. Specifically, your joints play an integral part in your ability to enjoy everyday activities, take care of yourself, and perform necessary functions every day. If you experience joint problems,  you may be left with pain, disability, loss of sensation and trouble keeping your balance.

For many people who face joint pain, loss of flexibility and trouble with mobility, treatments including medication and injections may be able to help. Additionally, engaging in regular exercise and maintaining a healthy diet often works to preserve joints and build strength. In some cases, however, these treatments are not enough to stop the loss of joint tissue. If your condition requires more serious repair, your physician may recommend surgery followed by knee replacement therapy.

What is Knee Replacement Therapy?

Knee replacement therapy is physical therapy that usually follows knee replacement surgery. During surgery, parts of the knee joint are replaced with prosthetic alternatives. Some people only require knee replacement for one knee, but you may need to have both knees replaced during the same procedure.

The materials used in a replacement knee can vary and may include metal-on-plastic, ceramic-on-metal and ceramic-on-ceramic. Each knee replacement procedure is different, and your doctor will discuss your options to help you make the right decision for your specific healthcare needs.

Who is Most Likely to Need Knee Replacement Therapy?

Although joint problems involving the knees can affect people of all ages, they tend to be more common among seniors. This is due to the fact that joints can wear out with time naturally. Lifestyle, occupation and environmental factors can all play a part in how fast or slow this process occurs. As such, Medicare recipients often wonder whether the program provides benefits for knee replacement therapy after surgery.

How does Medicare Cover Knee Replacement Therapy?

Medicare benefits cover knee replacement therapy in a variety of ways. Just like with virtually everything related to Medicare benefits, coverage is supplied for services and products that are deemed medically necessary. This means that knee replacement therapy will receive coverage as long as your doctor or specialist orders the procedure due to medical necessity.

If you are formally admitted as an inpatient into a hospital for the knee replacement surgery, Part A may cover your costs. Medicare Part B covers the surgical procedure if it is performed in an outpatient setting. Doctor visits, diagnostic testing, and imaging involved in your care may be covered under Part B, which will also covers durable medical equipment like crutches, wheelchairs and other mobility products. This is important since you may require the use of mobility aids temporarily after your knee replacement.

After surgery, your doctor may order physical therapy to help you recover. Part B will help cover the costs of physical therapy ordered by your doctor. After you’ve paid the Part B de4ductible, you’ll be responsible for 20% of the Medicare-approved amount as long as your provider accepts assignment. 

Inpatient Care for Knee Replacement Therapy

Medicare Part A supplies inpatient care coverage. Medicare benefits under Part A can be used while admitted to a hospital or skilled nursing facility as long as the facility is approved by Medicare. Part A does not cover services provided by healthcare professionals who are not employed by the facility. If someone is brought in from a nearby specialist’s office to render care before, during or after your knee replacement, you may receive separate billing under Medicare Part B.

Knee Replacement Therapy and Prescription Drugs

Any prescription medications you require related to your knee replacement therapy will be considered for coverage under Medicare Part D. This is optional prescription drug coverage, and it applies to medications listed under your plan’s formulary. Medicare Part D does not provide a benefit for over-the-counter medications or healthcare products. You may also have a limit as to the quantity of certain medications you can receive coverage for in a given benefit period.

Medicare Advantage and Knee Replacement Therapy

Medicare Advantage plans include the same Part A and Part B benefits as Original Medicare, but most plans offer additional coverage, including prescription drug coverage.  This means that knee replacement therapy will be covered by most Medicare Advantage plans just the same as it is covered by Original Medicare benefits. You may, however, have access to a network of care providers that you need to visit. A Medicare Advantage plan may also offer access to alternative therapies to assist in rehabilitation and joint preservation. Check with your plan for specific benefits and costs related to knee replacement surgery and physical therapy.