Whether it’s from an injury or just years of working, having shoulder pain and issues can cause a major disruption to your everyday life. Fortunately there are usually surgeries that can correct this and help to relieve some of the pain you feel, perhaps even completely replace your shoulder if needed.
If you’re on Medicare, though, you may not be pursuing the option of having surgery because you don’t think it’s going to be covered by your benefits.
Here’s some more information on shoulder surgery, and what kind of benefit coverage you can get from Medicare.
Why Is The Shoulder Joint So Important?
The shoulder is a very flexible joint that is very vulnerable to injury from everyday wear and tear. When you have damaged or hurt your shoulder, it can definitely affect your quality of life and how active you can be in your everyday life.
Even though the shoulder joint is pivotal to your ability to have a good quality of life, many times shoulder surgery or shoulder replacement is still considered elective.
You might like to read: Caregiver’s Guide to Managing Shoulder Replacement Patients
So, Does Medicare Cover Shoulder Replacement Surgery At All?
Due to the fact that Medicare typically doesn’t cover elective, or non-essential, surgeries many people who are on Medicare benefits may be concerned that their surgery won’t be covered and they won’t get any benefits.
However, shoulder replacement surgery is one of the areas where people on this benefit plan may be surprised.
Medicare will, actually, pay for a portion of your shoulder replacement as long as your doctor officially recommends that a shoulder replacement is medically necessary for your specific condition.
What Parts Of Shoulder Replacement Surgery Does Medicare Pay For?
After your doctor has certified to Medicare that the surgery is necessary to repair previously done damage or to prevent further damage – like arthritis – from setting in. Additionally, the doctor you are seeing must be one that is approved by and enrolled in Medicare.
There are a few different types of shoulder surgery that patients undergo, depending on the issues they are experiencing and where the damage is on their shoulder.
- Rotator cuff surgery
- Torn labrum surgery
- Arthritis surgery
- Fractured shoulder surgery
Each of these types of surgery will be partially covered under Medicare, no matter what type of Medicare plan you have.
Here’s what you need to know
Medicare Part A Coverage With Shoulder Replacement Surgery
When your open shoulder replacement surgery has been deemed medically necessary, Medicare Part A – which is the original Medicare – will cover part of your surgery.
This cover will also extend to any medication or therapy you receive while you are in the hospital. Even though Medicare does cover your medication and therapies while you are in the hospital, they will only cover them for a certain period of time.
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What Does Medicare Part B Cover For Shoulder Replacement Surgery?
Some shoulder replacement or repair surgeries can be done arthroscopically, which is a minimally invasive method of doing this repair.
This type of surgery will be done usually in a clinic or on an outpatient basis.
If it is determined that this is the method your doctor is going to use for your surgery, then the surgery will be covered under Medicare Part B.
Medicare Part B will also cover all your doctor’s appointments before and after the procedure. Additionally, these benefits will cover physical therapy for after the surgery – even if you have an open procedure – so that you heal properly.
If you need any equipment after the surgery – like a sling for support – then these benefits will also cover that support to help your shoulder heal properly.
Medicare Part C Coverage For Shoulder Surgery
If you have Medicare Advantage – which is Medicare Part C – then you will get all the benefits of part A and B, but you may also get prescription drugs covered for after the surgery.
Doctors may prescribe pain medication for you to go home with, which can really help you to get rest and ensure your shoulder heals up properly. If you can get those prescriptions covered then it can help cut down on the costs you need to pay out of pocket.
In order to ensure that your prescriptions for post-surgical medications are covered you will want to make sure that you are going to a pharmacy that is listed as an in-network provider.
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Are There Any Out-of-pocket Expenses For Shoulder Surgery?
Sometimes it can be hard to determine the amount of money you will need to spend yourself when it comes to having a shoulder surgery.
This can depend on a couple factors, the biggest being if the doctor has to do an open procedure or not. Open procedure will be more expensive and require more recovery time and physical therapy.
Your doctor, when recommending this procedure, will be able to give you a written estimate of exactly what you’re going to be billed for when they book the procedure.
This written estimate should include all of the potential costs you may incur and any services required during or after the procedure.
To help you budget, here is a list of probable out-of-pocket expenses you will need to pay for your shoulder surgery
- The Part A Medicare deductible is $1,408. This deductible will cover the first 60 days you are in the hospital or any other skilled care facility.
- If you need to be receiving care in a facility or hospital for longer than 60 days, you will need to pay $352 per day in coinsurance pay until day 90. After that, it will be $704 for using any lifetime reserve days.
- If your surgery is an outpatient surgery then you need to meet your annual deductible of $198 and make sure your monthly premiums of $144.60 are paid and up to date.
- You will need to pay 20% of the outpatient procedure costs.
- You’ll also need to pay 20% of any medical equipment prescribed (like an arm sling) and any physical therapy as needed for your shoulder to heal.
On top of this, there is a an online procedure price tool that can help you to determine the actual costs of any outpatient procedure before you go through with it. In order to make sure you get the most accurate pricing, you will need to check with your doctor for the exact name of the procedure or the billing code for that type of surgery.
You might like to read: Does Medicare Cover Robotic Surgery?
Alternatives To Shoulder Surgery
Going through shoulder surgery can be really invasive and it can take a long time to heal, which means you are not able to enjoy any quality of life for quite some time.
If you aren’t sure about going through with the shoulder surgery then you may have a few other options before you need to go through something this invasive.
Cortisone Injections
These shots can be used to help relieve pain caused by arthritis in almost any joint – including your shoulders. They are typically only given in a doctor’s office so this isn’t something that you can do yourself at home.
In order for this type of treatment to be covered, it will need be administered by a doctor that is approved by Medicare. Medicare Part C and D are the plans that cover the cortisone injections, but items like administrative costs may be covered under Part B.
Physical Therapy
If you go through with the shoulder surgery, you will need physical therapy afterwards in order to make sure your shoulder heals properly and you get a full range of motion back in your shoulder.
Before going through this whole procedure, though, you may want to try physical therapy too. This type of treatment can help with relieving pain and giving you mobility back in your shoulder.
You will need to get a prescription for physical therapy in order for it to be covered under your Medicare benefits, and you will need to ensure you are seeing a Medicare approved therapist for your treatment.
Pain Relievers
There may be some over the counter or prescription medications that you can take in order to relieve the pain you are experiencing with your shoulder.
A lot of shoulder pain will come from inflammation in the shoulder joint, and these medications can help reduce that so you are not in as much pain.
You might like to read: How To Check Status Of Medicare Card?
Stem Cell Therapy
This one may seem a little odd to be suggesting for shoulder issues, but stem cell therapy is very effective when it comes to tendon and muscle tears. It is sometimes even recommended for cartilage tears.
If the issue you’re experiencing is not with the shoulder joint itself then you may benefit from this alternative type of therapy to get some relief.
Unfortunately, this type of therapy is not approved by the FDA at this time so that means it is not covered by Medicare.
If you are interested in this type of treatment but aren’t sure what it’s going to cost then you can talk to your doctor to see how you may be able to start the process.
Treating a shoulder injury and getting relief from pain will give you a brand-new quality of life. It may take a while to heal, but if you can go through with the surgery it can really help you to get movement back.
