Does Insurance Cover the Cost of Knee Replacement?

When knee pain interferes with your ability to function, knee replacement can restore your mobility and improve your quality of life. One of the first questions patients considering knee surgery ask is whether insurance will cover all or part of the cost. This blog answers that question and details the out-of-pocket expenses you may face to help you prepare for surgery.

Table of Contents

• Does Private Health Insurance Cover Knee Replacement?
• Does Medicare Cover Knee Replacement?
• Medical Necessity and Insurance Coverage
• Knee Replacement Costs Usually Covered by Insurance
• Common Out-of-Pocket Costs Associated With Knee Replacement

Does Private Health Insurance Cover Knee Replacement?

Many knee replacement patients have private health insurance through their employer or through a public exchange. Private insurance plans cover some of the costs associated with medically necessary knee replacement surgery, though coverage varies by plan. Some surgeons participate in insurance, and some don’t. Depending on your insurance plan, there will be some costs associated with the surgeon. Patients should review their plan to determine how much their insurance will cover and how much they will need to pay out of pocket.

Factors to consider when using private insurance for your knee replacement include:

Deductibles, Copayments, and Coinsurance

Your deductible is the amount you must pay out of pocket before your insurance coverage kicks in. Your copayment is the amount you pay after the insurance covers its share. Copayments are set amounts, such as a $50 copayment you pay up front whenever you see a doctor. Coinsurance is a percentage of the total cost that you are responsible for, which often comes out to 20 to 30 percent of your bill.

Pre-authorization Requirements

Many insurance plans require patients to receive authorization before undergoing surgery to ensure coverage. Your surgeon’s office typically gets this approval. However, patients should confirm the authorization is in place to avoid unexpected charges after their procedure.

In-Network Provider Restrictions

If your insurance plan requires in-network providers, make sure your surgeon is in-network. Some plans offer lower coverage for services from out-of-network providers, which can help if you prefer to work with an out-of-network surgeon because of their reputation, technique, and experience.

Does Medicare Cover Knee Replacement?

Medicare also covers knee replacements deemed to be medically necessary. In this case, the type of knee surgery you have determines which part of Medicare covers the procedure. Medicare Part A covers inpatient surgeries, while Medicare Part B covers outpatient knee surgery. If you have a Medicare Advantage plan, your coverage may be different.

Coverage under Medicare Part A includes the time you spend in the hospital, including inpatient rehabilitation you may have. Medicare Part B covers assistive equipment that you might need after surgery, such as canes or crutches. Medicare Part D will cover any medications your doctor prescribes for your surgery and recovery.

Medical Necessity and Insurance Coverage

Both Medicare and private insurance limit coverage to “medically necessary” knee replacement surgery. Medical necessity is a standard that meets these criteria:

• The surgery follows accepted standards of medical practice.
• The procedure is appropriate for the patient’s specific condition.
• Convenience is not the primary reason for undergoing surgery.
• The surgery is not considered cosmetic or experimental.

Your surgeon may need to provide documentation that demonstrates the medical necessity of your procedure before your coverage is approved.

Knee Replacement Costs Usually Covered by Insurance

Insurance makes a life-changing surgery like knee replacement more affordable by covering these costs:

Preoperative Costs

Your insurance may cover care you receive before your surgery to diagnose your condition and document the medical necessity of knee replacement, including:

• X-rays and other imaging for diagnostic purposes
• Blood tests to ensure the safety of your procedure
• Your initial consultation with your surgeon

Surgery Costs

Numerous fees are included in the overall cost of your surgery, such as:

• Facility fee
• Anesthesia
• Surgeon’s fee
• Your artificial knee joint

Insurance may cover much or all of your total surgery cost, which can range from around $15,000 to $50,000, which means you will only pay for your deductible and copayment, according to your plan’s terms.

Recovery Costs

Depending on your insurance plan, you may have coverage for these recovery supplies and services:

• Follow-up appointments with your surgeon
• Durable medical equipment like canes or walkers
• Medications prescribed by your surgeon

If you encounter unexpected issues after surgery, your insurance should also cover any postoperative care you may need.

Rehabilitation Costs

Physical rehabilitation is a common part of knee replacement recovery. Some patients begin their rehab soon after surgery, while they are still in the hospital or surgical center. Therapy usually continues on an outpatient basis for a few weeks, until patients can resume regular activities. Insurance typically covers part or all of the cost, depending on the specifics of your plan.

Common Out-of-Pocket Costs Associated With Knee Replacement

No matter how comprehensive your insurance coverage might be, you are likely to encounter a few out-of-pocket expenses, such as:

• Deductibles, copayments, and coinsurance
• Prescription medications if your insurance doesn’t provide coverage
• Over-the-counter medications recommended by your doctor
• Home modifications, including ramps or bathroom grab bars
• Extended or upgraded durable medical equipment

Your surgeon will help you understand some of your out-of-pocket expenses. You can also research these costs before your surgery by talking to your insurance provider or getting estimates for home modifications. Knowing your out-of-pocket costs helps you prepare for the entire surgery and recovery experience.

Learn More About Your Options for Knee Replacement in Los Angeles

Knee replacement can reduce discomfort, restore mobility, and improve your quality of life. Dr. Jason Snibbe is a board-certified orthopedic surgeon who takes the time with each patient to determine whether surgery is the necessary next step. His advanced robotic joint replacement techniques offer several advantages over traditional knee replacement, including superior outcomes and faster recovery times.

To determine if you are a candidate for robotic knee replacement in Los Angeles, call our office at (310) 860-3048 or complete our online contact form to schedule your consultation with Dr. Snibbe today.