If you’re seeking pain relief and increased mobility in the shoulder area, one option is to have shoulder replacement surgery. Medicare will cover inpatient and outpatient procedures for shoulder replacement, as long as your doctor says it’s medically necessary. Each part of Medicare covers different services, procedures, items, and medications that you may need before, during, or after the surgery.
Even with Medicare insurance, you’ll likely face some out-of-pocket costs for the procedure, depending on your health plan. We’ll explain what each part of Medicare covers for shoulder replacement surgery.
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Which Parts of Medicare Cover Shoulder Replacement?
Many people need shoulder replacement surgery to repair their shoulder or to limit further damage to the joint. Your Medicare-approved doctor will confirm that your surgery is mandatory to heal or prevent continued damage caused by a disease (like arthritis). The kind of surgery you need will depend on many variables, including the degree of damage in the shoulder. Here are some common types of shoulder surgeries:
- Rotator cuff surgery
- Torn labrum surgery
- Arthritis surgery
- Fractured shoulder repair – dictated by the location and seriousness of the fracture.
Medicare Part A Coverage
There’s a chance that your required procedure is “open surgery” — an invasive option where a surgeon makes a big incision to repair or replace the shoulder.
If open shoulder replacement is medically necessary, Medicare Part A will cover a share of the cost, along with any medications or therapies provided during your hospital stay. Note that Medicare places limits on how long it will cover any inpatient facility stays, including visits in skilled nursing facilities and rehabilitation centers.
Medicare Part B Coverage
A doctor may also perform shoulder surgery “arthroscopically.” This is a minimally invasive procedure normally done in a freestanding clinic or hospital — on an outpatient premise.
If arthroscopic shoulder replacement surgery is medically necessary for you, Medicare Part B will cover a share of the cost. Part B also covers 80% of any durable medical equipment you need after surgery (like an arm sling), plus physical therapy and all your doctors’ appointments before AND after surgery.
Medicare Part C Coverage
If you have a Medicare Advantage (Part C) program, it’ll cover as much as Original Medicare (A and B) does — including the costs of inpatient or outpatient surgery. Depending on your plan type, it might also cover prescription drugs. We suggest using providers and pharmacies in your plan’s network to lower your out-of-pocket costs.
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Medicare Part D Coverage
Next, Medicare Part D will cover the pain medication prescribed for you to take following the surgery. All Part D drug plans have a formulary that lists the covered medications and the expected percentage of coverage.
Medigap Coverage
Those with Original Medicare may also have a Medigap (Medicare Supplement) plan. Depending on your policy, Medicare could cover some of the leftover out-of-pocket costs like copays, coinsurance, and deductibles for your shoulder replacement surgery!
Your Expected Out-of-Pocket Costs
Estimating your exact costs can be difficult, but here’s a general overview, assuming you have Original Medicare:
- If you have outpatient surgery, you’ll pay 20% of the Medicare-approved cost and the Part B annual deductible ($198) and monthly premium ($148.50 in 2021).
- If you have inpatient surgery, you’ll pay your Part A deductible of $1,484 — which covers the first 60 days of inpatient hospital care in a benefit period.
With Medicare Part C, Part D, or Medigap coverage, ask your plan provider to confirm costs and coverage amounts.
For all your Medicare questions, or to get a FREE insurance quote, call The Fussell Group Insurance Advisors at 1-877-874-0711.