Does Medicare Cover Hip Replacement? A Guide to Costs and Coverage

For many seniors, chronic hip pain is more than just an annoyance. It is a barrier to mobility, independence, and enjoying daily life. When non-surgical treatments like physical therapy or medication no longer help with the pain, hip replacement surgery often becomes the next path forward. However, the decision to undergo surgery brings financial questions that are just as important as the medical ones.

Navigating Medicare coverage for a major procedure like total hip replacement can feel complex. It is important to understand not just if it is covered, but how the different parts of Medicare work together to pay for the surgeon, the hospital stay, the anesthesia, and the months of rehabilitation that follow.

This guide provides a detailed breakdown of Medicare coverage for hip replacement surgery, helping you estimate potential out-of-pocket costs and prepare financially for your road to recovery.

What Conditions Qualify for Medicare Hip Replacement Coverage?

Before diving into the specific parts of Medicare, it is crucial to understand the "golden rule" of Medicare coverage: medical necessity. Medicare does not cover elective – or optional –procedures performed solely for convenience or without a demonstrated medical need. For a hip replacement to be covered, your healthcare provider must document that the surgery is medically necessary to treat a specific condition.

Qualifying Conditions

Typically, Medicare considers hip replacement medically necessary if you have:

• Severe Osteoarthritis: The most common reason for surgery, where the cartilage cushioning the hip joint wears away, causing bone-on-bone friction.
• Rheumatoid Arthritis: An autoimmune disease that inflames the joint lining, leading to damage.
• Post-Traumatic Arthritis: Damage resulting from a serious hip injury or fracture.
• Avascular Necrosis: A condition where blood supply to the ball of the hip joint is limited, causing the bone to collapse.
• Hip Fractures: Sudden injuries that require immediate surgical intervention to restore mobility.

The Role of Conservative Treatment

In many cases, Medicare and insurance providers look for proof that you have tried less invasive treatments before resorting to surgery. Your medical records should show that you have attempted options such as:

• Prescription or over-the-counter pain medications.
• Physical therapy to strengthen the muscles around the joint.
• Assistive devices like canes or walkers.
• Cortisone injections to reduce inflammation.

If these measures fail to alleviate pain or improve function, your doctor can make a strong case for the medical necessity of a total hip replacement, triggering Medicare coverage.

Breakdown of Coverage: Original Medicare (Part A and Part B)

How much does a hip replacement cost with Medicare?

When you have Original Medicare, coverage for hip replacement is split between Part A (Hospital Insurance) and Part B (Medical Insurance). Understanding which part pays for what is essential for estimating your final bill.

Medicare Part A: Inpatient Hospital Stays

If your surgery requires you to be admitted to the hospital as an inpatient, Medicare Part A is the primary payer for the facility costs. This includes:

• Room and Board: A semi-private room (a room shared with other patients) and meals during your stay.
• Nursing Care: General nursing services provided by the hospital staff.
• Hospital Supplies: Medications administered during your stay, operating room fees, and other facility charges.

Your Costs with Part A: For 2026, the Part A deductible is $1,736 for each benefit period. A benefit period is the way Medicare Part A measures your hospital and skilled nursing facility coverage. It begins the day you are admitted as an inpatient to a hospital (or skilled nursing facility) and ends after you have gone 60 consecutive days without inpatient hospital care or skilled nursing facility care. You must pay this deductible amount before Medicare starts covering your hospital costs.

You must pay this amount before Medicare starts covering your hospital costs.

• Days 1–60: $0 coinsurance after you meet the deductible.
• Days 61–90: $434 coinsurance per day of each benefit period.
• Days 91 and beyond: $868 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).

Most hip replacement patients stay in the hospital for 1 to 3 days, meaning you will likely only be responsible for the initial deductible, if you haven't already met it in a recent benefit period.

Medicare Part B: Medical Services and Outpatient Care

Regardless of whether you are an inpatient or outpatient, Medicare Part B covers the services provided by doctors and medical professionals. This is a critical distinction: even if you are staying in the hospital (Part A), the surgeon's fee is billed under Part B.

Part B covers:

• Surgeon and Assistant Surgeon Fees: The cost for the doctor actually performing the hip replacement.
• Anesthesiologist Services: The cost for sedation or general anesthesia during the procedure.
• Pre-operative Visits: Consultations, X-rays, and exams leading up to the surgery.
• Post-operative Visits: Follow-up appointments to monitor healing.
• Outpatient Procedures: If your surgery is performed at an Ambulatory Surgical Center (ASC) or as an outpatient in a hospital (where you go home the same day), Part B covers the facility costs as well.

Your Costs with Part B:

• Deductible: The annual Part B deductible is $283 in 2026.
• Coinsurance: After meeting the deductible, you typically pay 20% of the Medicare-approved amount for all services.

Important Note on Excess Charges: If your doctor does not accept "assignment" (meaning they don't agree to accept the Medicare-approved amount as full payment), they may charge up to 15% more than the Medicare rate. This is called a "Part B excess charge," and you would be responsible for paying it out-of-pocket unless you have supplemental coverage that handles it.

Inpatient vs. Outpatient Hip Replacement: Which Costs Less with Medicare?

One of the biggest factors influencing the cost of hip replacement is the setting. Traditionally, hip replacements were always inpatient procedures requiring several days of hospital recovery. However, medical advancements have made outpatient hip replacement more common for healthy candidates.

Inpatient Surgery

• Who it’s for: Patients with underlying health conditions (like heart disease or diabetes), those who lack support at home, or complex surgical cases.
• Coverage: Part A covers the facility/stay; Part B covers the doctors.
• Cost Implication: You pay the Part A deductible ($1,736) plus the Part B 20% coinsurance for doctor services.

Outpatient Surgery

• Who it’s for: Generally healthy, active patients who can safely recover at home immediately after the anesthesia wears off.
• Coverage: Part B covers the entire procedure including both the facility fees and the doctor fees.
• Cost Implication: You pay the Part B deductible ($283) plus 20% of the total cost of the surgery and facility fees.

Which is cheaper? It might seem like outpatient surgery is cheaper because the Part B deductible ($283) is much lower than the Part A deductible ($1,736). However, because you pay 20% of the entire cost under Part B (including the expensive facility fees), outpatient surgery can sometimes result in higher out-of-pocket costs than the fixed Part A deductible, depending on the total price of the surgery.

Before scheduling, ask your doctor explicitly: "Will I be admitted as an inpatient, or is this an outpatient observation stay?" The answer changes which part of Medicare pays and what your final bill looks like.

Medicare Advantage (Part C) Coverage

Medicare Advantage plans (offered by private insurance companies like Wellcare) are an alternative to Original Medicare. By law, these plans must provide at least the same coverage benefits as Original Medicare (Part A and Part B). This means if Original Medicare covers medically necessary hip replacement, your Medicare Advantage plan must cover it too.

However, the cost structure is different. Instead of the standard deductibles and 20% coinsurance, Medicare Advantage plans often use:

• Copayments: A fixed dollar amount for a hospital stay (e.g., $300 per day for the first 5 days) or a surgery.
• Networks: You typically need to use doctors and hospitals within the plan’s network (HMO or PPO) to get the lowest price.
• Prior Authorization: Unlike Original Medicare, which often relies on the doctor’s determination, Medicare Advantage plans frequently require pre-approval (prior authorization) before the surgery to confirm medical necessity.

The Out-of-Pocket Maximum Advantage A significant benefit of Medicare Advantage plans is the annual out-of-pocket maximum. Original Medicare has no cap on your 20% coinsurance. If a surgery is incredibly expensive or complications arise, your costs can keep climbing. Medicare Advantage plans cap your yearly spending. Once you hit your limit, the plan pays 100% of covered services for the rest of the year.

Does Medicare Cover Hip Replacement Rehab and Physical Therapy?

The surgery itself is only the first step. Recovery from a hip replacement involves a lot of rehabilitation to restore strength and range of motion. Medicare provides coverage for these aftercare services.

Physical Therapy (PT)

Physical therapy is essential for learning how to walk with a new hip. Your care team will design a program just for you, starting with gentle exercises soon after surgery. These exercises help rebuild muscle strength, improve balance, and restore joint movement, making it easier to get around safely. Sticking to your physical therapy plan can reduce pain and speed up your recovery, so you regain independence sooner. Types of physical therapy can include:

• Inpatient PT: If you receive therapy while admitted to the hospital, it is covered under Part A.
• Home Health PT: If you are homebound and require therapy at home, Part A or Part B covers 100% of the cost for eligible home health services.
• Outpatient PT: Once you are mobile enough to visit a clinic, Part B covers physical therapy. You pay 20% of the Medicare-approved amount after meeting your deductible.

Skilled Nursing Facilities (SNF)

Some patients need more help than family can provide at home but don't need to stay in a hospital. In this case, a short stay in a Skilled Nursing Facility (SNF) may be required.

Coverage Rule: Medicare Part A covers SNF care only if you had a qualifying inpatient hospital stay of at least 3 consecutive days prior to admission.

Costs

• Days 1–20: $0 coinsurance (fully covered).
• Days 21–100: Up to $204 per day coinsurance (in 2024).
• Days 101+: You pay all costs.

Durable Medical Equipment (DME)

You will likely need equipment to help you move safely during recovery. This falls under Part B coverage.

• Common Items: Walkers, canes, crutches, and hospital beds (if needed at home).
• Cost: You typically pay 20% of the Medicare-approved amount.
• Important: To be covered, the equipment must be prescribed by your doctor and purchased or rented from a supplier enrolled in Medicare. If you buy a walker from a store that doesn't accept Medicare assignment, you may have to pay the full cost yourself.

Prescription Drugs

Pain management is a key part of recovery.

• Inpatient Drugs: Medications given to you while you are an inpatient in the hospital are covered by Part A.
• Outpatient Drugs: Prescription painkillers, blood thinners (to prevent clots), and antibiotics you take at home are covered by Medicare Part D (prescription drug plans) or a Medicare Advantage plan with drug coverage.
• Cost: Depends entirely on your specific plan’s formulary (drug list) and tiers. Check with your plan to see which pain medications are covered and what your copay will be.

Estimating Your Total Costs: A Step-by-Step Guide

Because every surgery and plan is different, giving a single dollar amount for hip replacement is impossible. However, you can generate a fairly accurate estimate by following these steps.

1. Confirm the Setting (Inpatient vs. Outpatient) Ask your surgeon if you will be admitted as an inpatient or if the surgery is outpatient. This determines if you are paying the heavy Part A deductible or relying mostly on Part B coinsurance.
2. Ask About "Assignment" Verify that every provider involved, like the surgeon, anesthesiologist, and facility accepts Medicare assignment. This protects you from excess charges.
3. Check Your Supplemental Coverage
   • If you have a Medigap (Medicare Supplement) policy: Depending on your plan (Plan G and Plan N are popular), it may cover your Part A deductible and the 20% Part B coinsurance, leaving you with very little to pay out-of-pocket.
   • If you have Medicare Advantage: Look at your plan’s "Summary of Benefits." Specifically, look for the copay for "Inpatient Hospital Care" and "Ambulatory Surgical Center" services.
4. Use the Procedure Price Lookup Tool Medicare.gov offers a tool called "Procedure Price Lookup." You can enter the code for hip replacement (often CPT 27130 for total hip arthroplasty) to see national average costs for the surgery in both ambulatory surgical centers and hospital outpatient departments.
5. Factor in Pre- and Post-Op Costs Don't forget to budget for the deductible and coinsurance associated with pre-surgery MRI/X-rays, post-surgery physical therapy sessions (often 2–3 times a week for several weeks), and equipment rentals.

Common Questions About Medicare and Hip Replacement

Can I get a hip replacement on both hips at the same time? Yes, this is called a bilateral hip replacement. Medicare covers this if it is medically necessary and your doctor deems it safe. However, because it increases the complexity and recovery time, it is often performed as an inpatient procedure.

Does Medicare cover minimally invasive or robotic hip replacement surgery? Yes. Medicare coverage is based on the outcome (repairing the hip), not the specific tool the surgeon uses. As long as the robotic or minimally invasive technique is FDA-approved and medically necessary, Medicare covers it the same as traditional surgery. However, ensure the facility doesn't charge extra "technology fees" that Medicare might not reimburse.

What if my claim for hip replacement is denied? If Medicare or your Medicare Advantage plan denies coverage for your hip replacement, you have the right to appeal. The denial notice will explain why (often missing documents that show medical necessity). You can work with your doctor to provide more records or evidence that other treatments failed, resubmit the claim, and often get the decision reversed.

Does Medicare cover dental clearance for hip surgery? Surgeons often require you to get "dental clearance" before joint replacement to ensure no infections in your mouth could spread to your new hip. Unfortunately, Original Medicare does not cover routine dental exams, even for surgical clearance. However, many Medicare Advantage plans do include dental benefits that could cover this exam.

Summary Checklist for Planning Your Surgery

If you are considering hip replacement, use this checklist to help make the process easy:

• Doctor Consultation: Discuss the medical necessity and document all previous non-surgical treatments.
• Status Check: Ask if the surgery will be "Inpatient" or "Outpatient."
• Network Check: Make sure the hospital, surgeon, and anesthesiologist are in your plan's network (especially for Medicare Advantage).
• Plan Review: Look at your Medigap or Medicare Advantage plan details for deductibles, copays, and out-of-pocket maximums.
• Home Prep: Arrange for home health care or be sure a family member can help during the first few days.
• Equipment: Get a prescription for a walker or commode before surgery so it is ready when you return home.

Hip replacement is a major event, but with the right preparation, the financial aspect doesn't have to be a source of stress. By understanding how Part A and Part B work together, or how your Medicare Advantage plan structures its benefits, you can focus your energy where it belongs: on a successful recovery and a return to an active, pain-free life.

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