Does Medicare Cover Shoulder Replacement Surgery?

You might need shoulder replacement surgery to repair your shoulder or to reduce further damage to the joint.

Your doctor must certify that your surgery is required to heal or prevent ongoing damage caused by a disease, such as arthritis. This doctor must also be enrolled in and approved by Medicare.

Here’s 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 to repair or replace your shoulder.

If your open shoulder replacement is medically necessary, Medicare Part A will cover a portion of the cost. Part A is one part of Original Medicare.

Part A will also cover any medications or therapies you receive during your stay at a hospital, skilled nursing facility, or rehabilitation center, but 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 performed arthroscopically. This minimally invasive procedure is typically performed in a hospital or freestanding clinic on an outpatient basis.

If you have an arthroscopic shoulder replacement, your surgeon makes a small incision in your shoulder and places a small camera there. Through another small incision, your surgeon repairs or replaces portions of your shoulder.

If your arthroscopic shoulder replacement surgery is medically necessary, Medicare Part B — the other part of Original Medicare — will cover a portion of the cost.

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.

If you have a Part C plan, it’s important to use in-network healthcare professionals and pharmacies to keep your out-of-pocket costs down.

Medicare Part D coverage

Medicare Part D covers any drugs prescribed for you to take after surgery, such as pain medication. 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.

Medigap coverage

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-pocket 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:

• Medicare Part A premium: Most people pay no premium for Part A because they paid Medicare taxes long enough while working. However, if you or your spouse did not work at least 40 quarters of Medicare-covered employment (10 years), you may pay a premium of $278 or $505 in 2024, depending on how long you or your spouse paid Medicare taxes.
• Inpatient surgery: Your Part A inpatient hospital deductible is $1,632. This covers the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
• Coinsurance: If you require a longer stay, you will pay a coinsurance amount of $408 daily from day 61 through day 90 in a benefit period and $816 daily for any lifetime reserve days you use.
• Skilled nursing facility care: If you stay in a skilled nursing facility, your daily coinsurance cost from day 21 through day 100 in a benefit period would be $204 per day.
• Outpatient surgery: For outpatient surgery, you’re responsible for meeting your Part B annual deductible of $240, as well as your monthly premium, which is $174.70 for most people in 2024.
• Medicare-approved costs: You’ll pay 20% of the Medicare-approved cost of the outpatient procedure.
• Durable medical equipment and physical therapy: You’ll also pay 20% 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 your plan. You will most likely have some copay costs for any medications prescribed for you.

Your plan’s formulary and tier system set the costs per drug. Your plan provider can let you know what you will pay for each medication ahead of time.

Tip

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.

Shoulder replacement surgery is one option for relieving pain and increasing 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.