- Shoulder replacement surgery can relieve pain and increase mobility.
- This procedure is covered by Medicare, as long as your doctor certifies that it’s medically necessary.
- Medicare Part A covers inpatient surgeries, while Medicare Part B covers outpatient procedures.
- You may have to pay some out-of-pocket costs for shoulder replacement surgery, even with Medicare coverage.
Your shoulder is a flexible joint that’s highly susceptible to injury and wear and tear. A severely damaged shoulder could affect your quality of life. Even so, shoulder replacement surgery is often categorized as elective.
Because Medicare doesn’t typically cover elective surgeries, you may be concerned that you’ll have to live with pain or pay for the surgery out of pocket. But Medicare will, in fact, pay for a portion of the costs if your doctor states that shoulder replacement surgery is medically necessary in your specific case.
You might need shoulder replacement surgery to repair your shoulder or to reduce further damage to the joint.
Your doctor will need to certify that your surgery is required to heal or prevent ongoing damage caused by a disease, such as arthritis. This doctor must be enrolled in and approved by Medicare.
The type of surgery you need will depend on several factors, including the extent of the damage in your shoulder. Some common types of shoulder surgeries include:
- Rotator cuff surgery. Rotator cuff repair may be done arthroscopically or as an open surgery.
- Torn labrum surgery. This is usually done arthroscopically.
- Arthritis surgery. This is typically done arthroscopically but may require an open surgery if the damage to your shoulder is severe.
- Fractured shoulder repair. The type of surgery needed will be determined by the location and severity of the fracture or fractures.
Next, we’ll look at what’s covered under each part of Medicare.
Medicare Part A coverage
Open surgery is an invasive option that requires a surgeon to make a large incision in order to repair or replace your shoulder.
Part A will also cover any medications or therapies you receive during your stay at a hospital, skilled nursing facility, or rehabilitation center. But it’s important to know that there are limits to how long Medicare will cover a stay at any type of inpatient facility.
Medicare Part B coverage
Shoulder surgery may also be done arthroscopically. This type of surgery is minimally invasive and is typically done in a hospital or freestanding clinic on an outpatient basis.
If you have an arthroscopic shoulder replacement, your doctor will make a small incision in your shoulder and place a small camera there. Through another small incision, the surgeon will repair or replace portions of your shoulder.
Part B also covers these items and services as well, if needed:
- all of your doctors’ appointments before and after surgery
- physical therapy following surgery, which you’ll need no matter what type of procedure you have
- any durable medical equipment you need after surgery, such as an arm sling
Medicare Part C coverage
If you have Medicare Part C (Medicare Advantage), your plan will cover all the expenses covered by original Medicare (parts A and B). Depending on your plan, it may also cover prescription drugs.
To keep your out-of-pocket costs down, it’s important to use in-network providers and pharmacies if you have a Part C plan.
Medicare Part D coverage
Any drugs prescribed for you to take after surgery, such as pain medication, will be covered by Medicare Part D. Part D is optional prescription drug coverage that’s offered through Medicare.
Each Part D plan includes a formulary. This is a list of medications that the plan covers and the percentage of coverage you can expect.
If you have original Medicare, you might also have a Medigap plan. Depending on your plan, Medigap may cover some of the remaining out-of-pockets costs for your shoulder replacement surgery. This can include your copays, coinsurance, and deductibles.
Medigap typically covers medication copays through Part D. Note, though, that most plans are not allowed to cover the Part B premium.
It may be difficult to estimate your exact out-of-pocket costs before your procedure. Your doctor’s billing office should be able to give you a written estimate of what you can expect. This usually includes a range of potential costs, based on the services you might require during and immediately after the procedure.
Original Medicare costs
There are out-of-pocket costs that you can expect, even if you have Medicare. These include:
- For inpatient surgery, your Part A inpatient hospital deductible of $1,408. This covers the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
- If you require a longer stay, you will pay a coinsurance amount of $352 daily from day 61 through day 90 in a benefit period and $704 daily for any lifetime reserve days you use.
- If you stay in a skilled nursing facility, your daily coinsurance cost from day 21 through day 100 in a benefit period would be $176 per day.
- For outpatient surgery, you’re responsible for meeting your Part B annual deductible of $198, as well as your monthly premium, which is $144.60 for most people in 2020.
- You’ll pay 20 percent of the Medicare-approved cost of the outpatient procedure.
- You’ll also pay 20 percent of the costs for any durable medical equipment and physical therapy appointments.
Medicare Part C costs
If you have Medicare Part C, your costs will vary depending on the type of plan you have. Your insurer can give you specific coverage and copay details ahead of time. Typically, you can expect to pay some form of copay.
No matter which type of Part C plan you have, it’s legally required that your plan cover at least as much as original Medicare. This includes the costs of inpatient or outpatient surgery.
Medicare Part D costs
If you have Medicare Part D, your costs will differ based on the plan you have. You will most likely have some copay costs for any medications prescribed to you.
The costs per drug are set by your plan’s formulary and tier system. Your plan provider can let you know what to expect to pay for each medication ahead of time.
Medicare has a procedure price lookup tool, which could help you determine the cost of an outpatient surgery. To get the most accurate results, ask your doctor for the exact name of the procedure or the code for that type of surgery.
Before the procedure
The first step is making sure you’re healthy enough to undergo shoulder replacement surgery. Several weeks before your surgery date, your doctor will schedule a physical exam to assess your heart and overall health. At that time, your doctor may recommend that you stop taking certain medications, such as blood thinners.
Anticipating surgery can be stressful for many people. Try to relax as much as possible and get a good sleep the night before.
The day of the procedure
Your doctor will let you know when you need to stop eating and drinking before surgery. If you typically take daily medications in the morning, ask your doctor whether you should take them on the day of the procedure.
If you’re having an open surgery, you should be prepared to spend several days in the hospital. Bring anything that would make you feel more comfortable, such as a good book to read, your phone, and a phone charger.
About an hour before the procedure, an anesthesiologist will assess you. You’ll also meet with your surgeon, who will explain the procedure to you in depth. Use this time to ask any questions you have.
The amount of time required for shoulder replacement surgery varies, but it usually takes 2 to 3 hours. You’ll wake up in a recovery room, where you’ll stay for a period of time.
If your surgery was done on an inpatient basis, you’ll be taken to your room after spending several hours in recovery. If your surgery was done on an outpatient basis, you’ll need someone to pick you up after you’re discharged.
After the procedure
As with any surgery, some pain or discomfort can be expected. Your doctor will prescribe pain medication to help. You may be instructed to take your medication at specific times or before your pain level increases. You may also be told to apply ice to the area.
You’ll be discharged with your arm in a sling, which you may be told to wear for several weeks.
Physical therapy often begins immediately, sometimes even on the day of the procedure. Using your shoulder as directed will help you gain mobility more quickly. Your doctor will give you a prescription to continue physical therapy as long as it’s necessary
Your shoulder and arm will start to improve slowly. Within 2 to 6 weeks, you can expect to feel and see significant improvement and can resume many of the activities of daily living.
It may take longer for you to drive a car or play sports, though. You might not be able to carry heavy packages for several months. It also may take 6 months or longer before you have full mobility in your shoulder.
A shoulder replacement can last for 15 to 20 years.
Unless you have an injury that requires immediate repair, such as a broken or fractured shoulder bone, your doctor may recommend trying alternatives to surgery first.
Cortisone shots can be used to relieve pain and inflammation in the shoulder joint. They’re usually administered in a doctor’s office and must be given by a Medicare-approved doctor in order to be covered.
Most Part D and Part C plans cover cortisone injections. Other portions of your bill, such as administrative costs, may be covered by Part B.
Physical therapy can help with pain, mobility, and stabilization of the joint. Medically necessary physical therapy sessions are covered by Medicare Part B, provided you have a prescription from a Medicare-approved physician. You also must use a Medicare-approved physical therapist.
Prescription medications for pain are covered by most Part D and Part C plans. Some Part C plans also cover over-the-counter medications for pain.
Stem cell therapy
This treatment may be recommended for partial tendon or muscle tears. It may also be recommended for cartilage damage. But it’s not currently approved by the FDA, which means it’s not covered by any part of Medicare.
- Shoulder replacement surgery can be one option to relieve pain and increase mobility. You can also try nonmedical treatments.
- Medicare covers inpatient and outpatient shoulder replacement procedures, as long as they’re deemed medically necessary.
- Each part of Medicare will cover different procedures, services, medications, and items you may need throughout the process.
- Out-of-pocket costs with original Medicare coverage are pretty straightforward. With Part C, Part D, or Medigap coverage, you may want to confirm coverage amounts and costs with your plan provider.