Does Medicare Cover Joint Replacement Surgery in New Hampshire?

Yes. Medicare covers knee, hip, and shoulder replacement surgery for New Hampshire residents when a doctor documents that it is medically necessary. That part is settled. What trips people up is the bill, because two people in the same New Hampshire hospital having the same operation can owe wildly different amounts.

The difference comes down to two things: whether you are admitted as an inpatient or treated as an outpatient, and what kind of coverage you carry alongside Medicare.

Here is how the money actually works in 2026, and what NH residents should check before the surgery gets scheduled.

What "medically necessary" means for a joint replacement

Medicare does not pay for a new knee because your knee aches. It pays when the record shows the joint is damaged, the damage limits what you can do, and the cheaper options already failed.

In practice, your surgeon builds a file that usually includes:

• Imaging showing joint damage, typically X-rays and sometimes an MRI
• Documented pain that interferes with walking, sleeping, or daily tasks
• A record of conservative treatment you already tried, such as physical therapy, cortisone or hyaluronic acid injections, braces, or anti-inflammatories
• A note that those treatments did not give you lasting relief

Getting there is rarely quick. "In most cases, regardless of whether you have Original Medicare, Medicare Supplement or a Medicare Advantage plan, you will be asked to try physical therapy first prior to hip replacement," says Laura Shipman, a licensed Medicare agent in Olathe, Kansas. "Most of my customers who have needed hip replacement have been able to have the surgery completed without any issues."

That step-therapy expectation is not written into federal law as a hard rule. It comes from the medical necessity standard each Medicare contractor and each Medicare Advantage plan applies, and it does vary. Some New Hampshire orthopedic practices move faster than others on documentation.

Inpatient or outpatient? This decides your bill

Joint replacements used to mean a hospital admission and a few nights in a bed. Not anymore.

Medicare keeps what it calls the Inpatient Only list, a set of procedures it will only pay for as an admission. Total knee replacement came off that list in 2018. Total hip followed in 2020. Shoulder replacement came off more recently, after a couple of reversals along the way.

In 2026 CMS went further and started dismantling the list entirely. The agency finalized a rule removing 285 procedures, most of them musculoskeletal, effective January 1, 2026, with the whole list scheduled to disappear by 2029. Joint replacements were in that first batch.

Practical translation: most knee, hip, and shoulder replacements are now billed as outpatient procedures, even when you stay overnight. Many happen at ambulatory surgery centers.

Why that matters for your wallet:

• Outpatient falls under Medicare Part B. You pay the $283 annual deductible, then 20% of everything Medicare approves, with no ceiling.
• Inpatient falls under Part A. You pay the $1,736 deductible per benefit period and nothing more for days 1 through 60.

Being kept overnight for observation is not the same as being admitted. If the hospital bills you as an outpatient under observation status, Part B rules apply no matter how long you were in the building. Ask what your status is before you leave.

What you pay with Original Medicare alone in New Hampshire

This is where the damage happens. Original Medicare has no out-of-pocket maximum. Twenty percent of a joint replacement is not a small number.

"If as an outpatient surgery, which most hip, knee, and shoulder replacements fall under, Medicare Part B would pay 80% of the cost. The other 20% would be on the beneficiary," says Ted Wallus, a licensed Medicare agent in Boston, Massachusetts. "That would be a sizeable bill, hence why so important to get additional coverage."

Agents who price these out for clients regularly put the coinsurance somewhere in the range of roughly $900 at a surgery center to roughly $1,700 at a hospital outpatient department, before you add physical therapy visits, imaging, and follow-up appointments. You can check the national averages and your own share for a specific procedure code using Medicare's Procedure Price Lookup tool.

And the 20% keeps coming. Every therapy session, every post-op visit, every follow-up X-ray carries its own 20%.

How Medigap changes the math

A Medicare Supplement plan is built to absorb exactly this kind of bill. For a New Hampshire resident facing a joint replacement, it is the difference between a four-figure surprise and a bill you already budgeted for.

Plan G, the most popular choice for new enrollees, covers the Part B coinsurance in full. You pay the $283 Part B deductible for the year and Plan G handles the rest, including the therapy visits afterward.

Plan N works the same way with two small exceptions: up to $20 for an office visit and up to $50 for an emergency room visit that does not lead to admission. For a surgical episode the difference between Plan G and Plan N usually comes out in the wash.

One catch worth knowing. If you are past your Medigap open enrollment window, insurers in most states can turn you down or rate you up based on health history, and a knee scheduled for next month is exactly the sort of thing underwriting asks about. Guaranteed issue rights exist, but they are narrow.

How Medicare Advantage handles joint replacement

Advantage plans have to cover anything Original Medicare covers. Where they differ is the paperwork and the network rules you have to clear first.

Costs on an Advantage plan usually show up as flat copays. A few hundred dollars for an outpatient surgery is common, or a per-day hospital copay if you are admitted. Physical therapy comes with its own copay per visit, which adds up fast when the surgeon prescribes 12 sessions. Everything counts toward your plan's annual out-of-pocket maximum, which Original Medicare does not have.

Three things to check before scheduling:

1. Prior authorization. Nearly every Advantage plan requires it for a joint replacement. Your surgeon's office submits it, but you should confirm it was approved in writing before the date.
2. Network. The surgeon, the anesthesiologist, the facility, and the therapy clinic all need to be in network. They are not always all in the same network.
3. Site of service. Some plans steer you toward an ambulatory surgery center with a lower copay. Others will only approve the hospital.

Prior authorization timelines tightened in 2026. Under a CMS rule that took effect January 1, Advantage plans must decide standard requests within 7 calendar days and expedited requests within 72 hours, and they have to give a specific reason for any denial. If you get denied, that reason is your roadmap for the appeal.

Rehab, therapy, and getting home

The surgery is the short part. Recovery is where coverage questions pile up.

Physical therapy is covered under Part B, outpatient, at 20% coinsurance per visit. There is no longer a hard annual dollar cap, but your therapist does have to document that the treatment is still medically reasonable past a certain spending threshold.

Skilled nursing. If you need a rehab facility, Part A can cover up to 100 days per benefit period, but only after a qualifying 3-day inpatient hospital stay. That is the trap. Most joint replacements are now outpatient, so there is no 3-day inpatient stay, so the 100-day skilled nursing benefit never opens. Medicare Advantage plans can waive that 3-day requirement. Original Medicare cannot.

Home health. If you are homebound after surgery and need skilled care, Medicare covers home health visits at no cost to you under Part A or Part B.

Equipment. Walkers, crutches, commodes, and continuous passive motion devices fall under durable medical equipment. Part B pays 80% and you owe the other 20%, and the supplier has to be Medicare-enrolled.

What about robotic-assisted surgery?

Medicare pays the same amount whether your surgeon uses a robotic arm or does the procedure by hand. There is no separate robotic benefit and no extra charge to you for the technology itself. The operation is covered because it is a knee replacement, not because of how it was performed.

If a facility tries to bill you extra for the robot, that is a billing question worth pushing back on. Ask for an itemized statement.

Before you schedule: a NH checklist

1. Ask the surgeon's office, in these words: will I be billed as inpatient or outpatient?
2. Ask where the procedure will happen. Surgery center and hospital outpatient department carry different price tags.
3. If you have an Advantage plan, get the prior authorization approval number before the date.
4. Confirm every provider involved is in network, including anesthesia and the therapy clinic.
5. Ask the therapy clinic how many visits the surgeon ordered, then multiply by your copay or coinsurance.
6. If you only have Original Medicare and no supplement, price a Medigap plan now, not after the surgery is on the calendar.

Costs for the same procedure vary by facility and by county, and New Hampshire is no exception. A licensed agent who writes plans in NH can pull your specific plan's copay for an outpatient joint replacement in a couple of minutes, which beats guessing.