Utah · Medicare · Knee and hip replacement, inpatient vs. outpatient, and what you pay

Does Medicare Cover Knee & Hip Replacement in Utah? (2026)

Yes. Medicare covers total knee and hip replacement when it is medically necessary, and Utahns use the benefit more than almost anyone: 2.88% of Utahns in Original Medicare had a knee or hip replaced in 2024, against 1.66% nationally. Most of those operations are now outpatient, which changes which part of Medicare pays, what the facility bill looks like, and whether a nursing-home stay afterward is covered. Here is what Medicare pays and does not, what the surgeon, the facility and the rehab cost a Utah patient in CMS's own claims files, which Utah hospitals do the most, and how a Medigap policy or a Medicare Advantage plan changes what you owe.

Utah Retirement Income Data Desk

Reviewed by Brian Penner, Retirement income & long-term care planner · Published October 5, 2026

A knee or hip replacement is the operation that ends most severe arthritis of those joints, and for people on Medicare it is as routine as surgery gets. Medicare.gov's surgery page says Medicare covers “many medically necessary inpatient and outpatient surgical procedures,” and joint replacement for arthritis that has failed medicine, injections and therapy is squarely on that list. The question is never whether it is covered; it is which part of Medicare pays, which depends on a one-line decision in the hospital, and how much the building you have it in charges. Those two things, together with the rehab afterward, decide the bill. This article puts Utah numbers on each piece from CMS's own claims files, which show one thing above all: the operation has moved out of the inpatient hospital. Of 5,288 total knee and hip replacements billed by Utah surgeons for Original Medicare patients in 2024, at most 613 were inpatient stays. That shift is good news for recovery and mostly good news for cost, but it quietly removed the thing many families still count on, a Medicare-covered nursing-home stay afterward.

What does Medicare cover for a knee or hip replacement, and what does it not?

The covered list is long. Medicare pays for the orthopedic surgeon's evaluation, the X-rays and any MRI, the cortisone or other joint injections tried first, the surgery itself, the implant, the anesthesia, the hospital or surgery center, the post-operative visits (bundled into the surgeon's fee for 90 days), physical therapy in the hospital, at home or as an outpatient, a walker or crutches, a raised toilet seat and similar equipment only if it meets Medicare's definition of durable medical equipment, home health nursing and therapy if you are homebound, and, if you qualify, a skilled nursing facility or an inpatient rehabilitation hospital. Which part pays depends on your status. Medicare.gov's inpatient page says Part A “usually covers inpatient hospital care,” including a semi-private room, meals, general nursing and drugs, and that if you also have Part B “it generally covers 80% of the Medicare-approved amount for doctors' services you get while you're in a hospital.” If you are an outpatient, everything is Part B: Medicare.gov's outpatient hospital page says you “usually pay 20%” of the approved amount for the doctor and a copayment to the hospital for each service, and that “in most cases, the copayment can't be more than the Part A deductible for each service.” In a surgery center you pay 20% “to both the ambulatory surgical center and the doctor(s) who treat you.”

The not-covered list is short. A private room unless medically necessary, a television or phone, personal items, private-duty nursing and, outside the hospital, a hospital bed or shower chair that does not meet the durable medical equipment definition. Medicare does not pay for a nursing home unless you had a qualifying inpatient stay (more on that below), does not pay for custodial help at home, and does not pay the difference if you choose a surgeon who does not accept assignment and charges up to 15% more than the approved amount. One misconception is worth clearing up: Medicare has no rule that you must try a certain number of injections or months of therapy first. The surgeon documents that conservative treatment has failed and that you are a candidate, and for an Original Medicare patient there is no prior authorization step at all. Medicare Advantage plans are a different matter, covered below.

Is joint replacement inpatient or outpatient, and why does it matter so much?

For decades a knee or hip replacement meant three or four nights in the hospital under Part A. CMS has since taken both total knee and total hip replacement off its “inpatient-only” list, which means a hospital may do them as outpatient procedures, and both appear on CMS's 2026 list of procedures Medicare pays for in ambulatory surgery centers. Whether you are an inpatient is now a doctor's order, not the operation. Medicare.gov's rule is that you are an inpatient “starting when you're formally admitted to the hospital with a doctor's order,” that an admission “is generally appropriate when you're expected to need 2 or more midnights of medically necessary hospital care,” and that if you go “to a hospital for outpatient surgery, but they keep you overnight,” you are still an outpatient. Our observation status guide explains that distinction in detail. CMS's claims files show how completely Utah has moved.

Surgeon counts: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024, facility-setting rows for 27447 and 27130, counted by the state of the surgeon. Outpatient: CMS, Medicare Outpatient Hospitals by Geography and Service, 2024, APC 5115 rows for 27447 and 27130. Inpatient: CMS, Medicare Inpatient Hospitals by Geography and Service, 2024, MS-DRG 470 (566 Utah discharges) and 469 (47); these DRGs also include a small number of other lower-extremity joint procedures and exclude hip replacements done for a hip fracture, so the inpatient share is an upper bound. The three files count different things (people, services, discharges) and the surgeon file includes out-of-state patients, so the shares are approximate.

The direction is unmistakable and still moving. Utah inpatient joint replacement discharges fell from 634 in 2023 to 566 in 2024 (11%), while the number of knees and hips billed by Utah surgeons rose. Hospital outpatient volume for this procedure group fell too, from 4,886 patients to 3,666 (25%), which points to the one setting CMS does not publish by state: the freestanding surgery center. Nationally inpatient discharges fell 16% in the same year. Why it matters comes down to three things. An inpatient owes the Part A deductible, $1,736 in 2026, for the whole stay and nothing more per day for 60 days; an outpatient owes a Part B copay to the hospital that Medicare caps at the same $1,736 per service, or 20% with no cap in a surgery center. A Medicare Advantage plan's copays differ between the three settings, sometimes by a lot. And only an inpatient stay of three or more days unlocks a skilled nursing facility afterward.

What did a knee or hip replacement actually cost Utah patients?

CMS publishes every Original Medicare claim by billing code and by the state of the provider, which lets us see what Utah orthopedic surgeons were paid in 2024 and therefore what the 20% share came to. The surgeon's fee is the first bill, and it is the same whether you are an inpatient or an outpatient.

Beneficiaries are distinct people with at least one claim for the code in 2024; for the surgery codes we count the facility-setting row (the surgeon's claim for an operation in a hospital or surgery center) and omit the small office-setting rows, which reflect split surgical and post-operative billing. The injection and exercise rows sum office and facility settings and cover every joint and condition, not only joint replacement. Your share assumes the Part B deductible has been met and the surgeon accepts assignment. Denominators are people with Part B in Original Medicare during 2024 (Utah 183,494; national 27,982,142). Medicare Advantage encounters are not in this file. Sources: CMS, Medicare Physician & Other Practitioners — by Geography and Service, 2024 — data.cms.gov; CMS, Medicare Monthly Enrollment — data.cms.gov.

Three things stand out. First, the surgeon's fee is a small part of the whole: $1,572.50 on average for a knee, which includes the operation and every follow-up visit for 90 days, so the patient's 20% is about $314.50. Second, Utah's volume is rising fast: total knee replacements went from 3,165 in 2022 to 3,393 in 2023 to 3,443 in 2024 (up 8.8% in two years) and total hips from 1,608 to 1,757 to 1,845 (up 14.7%), while national knee volume fell slightly from 296,227 to 292,550. Third, the joint injection that usually comes first is one of the most common things Utah orthopedists do: 18,999 Utahns in Original Medicare had a large joint injected or drained in 2024, 10.4% of Part B enrollees against 8.7% nationally, at about $12.00 each at 20% plus the cost of the drug.

Why does the facility bill depend on the building?

The second bill, from the facility, is where the money is, and the implant is inside it. Medicare pays three different prices for the same operation depending on where it is done, and your share is calculated three different ways. In its January 2026 payment addenda, CMS sets the national rate for a total knee or hip replacement done in a hospital outpatient department at $12,665.27, the group CMS calls “Level 5 Musculoskeletal Procedures,” and in an ambulatory surgery center at $9,393.16 for a total knee and $9,614.11 for a total hip. For an inpatient, the hospital is paid a flat amount per discharge, which in Utah in 2024 averaged $13,821.14 from Medicare for an uncomplicated joint replacement (MS-DRG 470), against an average submitted charge of $69,155.87. CMS's hospital claims file confirms the Utah outpatient figure: in 2024 the average Medicare-approved facility amount for an outpatient total knee replacement in a Utah hospital was $11,743.35 (national $12,381.16) and for a total hip $11,691.42, of which Medicare paid about $10,109.62 and the patient or a supplemental policy owed the rest.

Sources: CMS, January 2026 ASC Addenda, Addendum AA (ASC rates for 27447, 27130 and 27446) and Addendum FF (January 2026 OPPS rate for APC 5115), CY 2026 OPPS/ASC final rule — cms.gov; Medicare.gov, Outpatient hospital services (copayment cap) and Inpatient hospital care (2026 deductible and daily amounts); CMS, Medicare Outpatient Hospitals — by Geography and Service, 2024 — data.cms.gov; CMS, Medicare Inpatient Hospitals — by Geography and Service, 2024 — data.cms.gov. ASC and OPPS rates are national figures before geographic wage adjustment; Utah averages are actual 2024 claims.

The surprising result is that for a person in Original Medicare with no Medigap policy, the three settings cost about the same in 2026: roughly $2,051 for an inpatient knee ($1,736 plus the surgeon's $314.50), $2,051 as a hospital outpatient, and $2,193 in a surgery center, before anesthesia, therapy and the Part B deductible. For a hip the figures are $1,998, $1,998 and $2,185. The copay cap is the reason: Medicare's rule that an outpatient hospital copay cannot exceed the inpatient deductible happens to bite at exactly this price range, so the hospital outpatient department, which Medicare pays the most, costs the patient slightly less than the surgery center, which Medicare pays the least. If you hold a Medigap policy the setting changes nothing for you, because Plan G pays the Part A deductible, the outpatient copay and the 20% alike. If you are in Medicare Advantage, the plan's Evidence of Coverage lists three different copays, for “inpatient hospital,” “outpatient hospital surgery” and “ambulatory surgical center,” and the gap between them can be several hundred dollars in either direction, so ask the surgeon's scheduler which one applies before the date is set.

Which Utah hospitals do the most Medicare joint replacements?

CMS publishes inpatient joint replacement discharges by hospital, which is the only facility-level view available (outpatient and surgery-center volumes are not published by provider). In 2024, fourteen Utah hospitals had at least eleven inpatient Original Medicare joint replacements; the rest had fewer and are suppressed.

Original Medicare inpatient discharges for MS-DRG 470 (major hip and knee joint replacement without major complication); hospitals with fewer than 11 discharges are suppressed by CMS. The submitted charge is the hospital's list price; the Medicare payment is what Medicare actually paid per discharge, excluding the patient's deductible and any supplemental payments, and it varies with each hospital's wage index, teaching status and add-ons. A high inpatient count does not mean a hospital does more joint replacements overall; it may mean it admits more of its patients. Source: CMS, Medicare Inpatient Hospitals — by Provider and Service, 2024 — data.cms.gov.

Two of those hospitals, Castleview in Price and St. George Regional, are among the three Utah hospitals that CMS placed in its Transforming Episode Accountability Model (TEAM) on January 1, 2026, along with Ashley Regional Medical Center in Vernal. TEAM is mandatory for every acute-care hospital in the metro areas CMS selected, and lower-extremity joint replacement is one of its five surgeries. CMS describes it this way: participating hospitals “coordinate care from surgery through 30 days post-hospitalization for people with Original Medicare,” receive “a target price to cover all costs associated with the episode of care, including the cost of the hospital inpatient stay or outpatient procedure and items and services following hospital discharge, such as skilled nursing facility stays or provider follow-up visits,” and “must refer patients to primary care services.” If spending comes in under the target the hospital can earn a payment; if over, it may owe one. For you as a patient, nothing about coverage or cost-sharing changes, and you keep the right to choose any provider. What changes is the incentive: the hospital now has a financial reason to send you home with home health rather than to a nursing facility, to make sure you have a primary care doctor, and to keep you out of the emergency room for 30 days. It runs through December 31, 2030.

Source: CMS, TEAM participant list, acute care hospitals as of August 18, 2026 — cms.gov; model description: cms.gov — TEAM. No Wasatch Front hospital is on the list; the Salt Lake City, Ogden and Provo metro areas were not among the selected areas.

How does Utah compare with the nation on joint replacement?

Utahns on Medicare are far more likely to have a joint replaced than other Americans. Both total knee and total hip replacement run well above the national rate, and the follow-on operations do too, which is what you would expect in a state where many more first replacements were done ten and twenty years ago.

Share of people with Part B in Original Medicare who had each service billed in 2024; Utah bars solid, national bars lighter; bars scaled to the largest value. Source: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024.

Utah runs 1.79 times the national rate for total knee replacement, 1.63 times for total hip, 2.10 times for a full knee revision, and about the national rate for partial knee replacement. Two cautions. The file counts people by the state of the surgeon, so it includes patients who travel to Utah for surgery and excludes Utahns operated on elsewhere, and it covers Original Medicare only, so none of the 269,226 Utahns in Medicare Advantage in June 2026 (54.9% of the state's 490,235 beneficiaries) is in it. The likeliest explanations are the ordinary ones: Utah's retirees hike, ski, garden and expect to keep doing so; the state has a deep bench of joint surgeons and surgery centers along the Wasatch Front and in St. George; and, as the next table shows, arthritis is common in the rural counties where people have spent a lifetime doing physical work.

Which Utah counties have the most arthritis?

CMS does not publish joint replacement by county, but the CDC estimates, for every county, the share of adults who have been told by a doctor that they have arthritis. The counties at the top are rural, older and, for the most part, hours from a joint surgeon.

Adults 18 and older ever told by a health professional that they have some form of arthritis, crude (not age-adjusted) model-based estimates from the 2023 Behavioral Risk Factor Surveillance System; the United States figure is 25.4%. 15 of 29 Utah counties are above the national figure. Crude rates reflect each county's age mix, which is why young Utah and Cache counties read lowest; small-county estimates have wide confidence intervals. Source: CDC PLACES, county data, 2025 release — data.cdc.gov.

Piute, Daggett, Wayne, Kane and Carbon lead the state, and Washington County, at 28.3%, is the highest of Utah's large counties, which fits what the hospital table shows: St. George Regional is the state's third-busiest inpatient joint replacement hospital and Castleview in Price, Carbon County's hospital, its second. For a rural reader the practical point is that the cost of a knee replacement includes the drive. A Wayne or Garfield County patient's nearest listed surgeons are in Richfield, Cedar City or St. George, and a course of outpatient physical therapy afterward is two or three trips a week for several weeks, which is one reason home health therapy, covered in full, matters more in rural Utah than the cost tables suggest.

What does Medicare pay for after the operation?

Recovery is where joint replacement differs from most surgeries, and where the inpatient-outpatient line does its real damage. There are four paths home, and Medicare treats them very differently.

1. Home health care: covered in full. If you are “homebound,” which Medicare.gov defines as having “trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches)” and leaving “takes a lot of effort,” a Medicare-certified agency can send a nurse and a physical therapist to your house, and Medicare.gov says “you pay nothing for covered home health services.” A doctor must certify the need, and almost every joint replacement patient qualifies for the first week or two. Our home health guide covers how to arrange it before you leave the hospital.
2. Outpatient physical therapy: 20% with no cap. Once you can get to a clinic, Part B pays 80% of the approved amount. Medicare.gov says there is “no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year”; the old therapy cap is gone, and in 2026 the only thing that happens when your therapy charges pass $2,480 is that the therapist adds a billing code confirming the care is still necessary. At the 2024 Utah average of $22.06 per 15-minute unit of therapeutic exercise, a one-hour session of four units was about $88.24 approved and $17.65 at 20%.
3. A skilled nursing facility: only after a three-day inpatient stay. Medicare.gov's rule is “a prior medically necessary inpatient hospital stay of at least 3 days in a row (starting the day you were admitted as an inpatient, but not including the day you leave the hospital),” and it adds that “time you spend at the hospital under observation or in the emergency room before you're admitted doesn't count.” An outpatient joint replacement with an overnight stay does not qualify, and most inpatient ones are discharged on day one or two. If you do qualify, Part A pays days 1 to 20 in full and you pay $217 a day for days 21 to 100 in 2026. Medicare.gov notes that Medicare Advantage plans “may also waive the 3-day minimum” and that some Accountable Care Organizations have a waiver; the TEAM hospitals above can also use one for qualifying facilities. Our 100-day skilled nursing guide has the details.
4. An inpatient rehabilitation hospital: covered, rarely used for a routine joint. Part A covers an inpatient rehab facility when a doctor certifies you need intensive therapy with physician supervision, under the same deductible and daily amounts as a hospital, and you pay no second deductible if you transfer directly or within 60 days. For an otherwise healthy person with one new joint it is seldom ordered; for someone with both knees done at once, or other serious conditions, it can be.

Equipment is the last piece. A walker, including a rollator, is covered under Part B at 20% after the deductible if a doctor prescribes it for home use and the supplier is enrolled in Medicare and accepts assignment; Medicare.gov warns that if the supplier “won't accept assignment, you may be charged more,” and that for rented items the supplier must accept assignment for every rental month. Crutches and a cane are covered the same way. A raised toilet seat, grab bars and a shower chair are generally not, because Medicare does not consider them medical equipment. Our durable medical equipment guide covers the supplier rules, and if the surgery was prompted by a fall or you worry about one, our falls guide is the companion piece.

Can you find a Utah orthopedic surgeon who takes Medicare?

Yes, nearly all of them do. CMS's clinician file lists 264 clinicians with a Utah practice location whose primary specialty is orthopedic surgery, and 247 of them, 94%, accept assignment, meaning they take the Medicare-approved amount as payment in full. The other 17 are non-participating and may charge up to 15% more than the approved amount, an “excess charge” that on a $1,572.50 surgeon's fee would be about $235.88; Medigap Plan G pays it and Plan N does not. With Original Medicare you need no referral to see any of them. The file lists surgeons by the practice address they enrolled with, so a group's billing office can inflate a small town's count.

Clinicians whose primary specialty in the CMS file is orthopedic surgery, counted once per clinician per city; a surgeon who practices in two cities appears under both, so the column does not sum to 264. Fillmore's count reflects a group enrolled at a Fillmore address rather than 19 surgeons practicing there. Subspecialists such as sports medicine and hand surgeons are included; many Utah joint replacements are also done by surgeons listed under other primary specialties. Source: CMS, Doctors and Clinicians National Downloadable File — data.cms.gov.

How do Medicare Advantage and Medigap each handle a joint replacement?

More than half of Utah's Medicare population, 269,226 of 490,235 people in June 2026, is in a Medicare Advantage plan. Those plans must cover joint replacement, but on their own terms: an in-network surgeon, hospital or surgery center, a referral in most HMOs, and in nearly every plan prior authorization before the surgery date is set, which is where joint replacements most often get delayed or denied. The cost-sharing is the plan's, not Medicare's: a flat copay per day for the first several inpatient days, a separate outpatient surgery copay that differs between a hospital and a surgery center, a copay per physical therapy visit, 20% or a copay for the walker, and, if a skilled nursing facility is approved, a daily copay that often starts before day 21. Many plans waive the three-day hospital rule for skilled nursing but require their own authorization for the facility and review the stay week by week. The in-network out-of-pocket limit caps the year, and a joint replacement with therapy and equipment can reach a fair share of it.

In Original Medicare with a Medigap policy, each bill, hospital or surgery center, surgeon, anesthesia, therapy, walker, is the Medicare amount described above, and the policy pays it. Plan G pays the Part A deductible, the outpatient copay, the 20% and any excess charge, leaving you the $283 Part B deductible; Plan N pays the same except for a copay of up to $20 for office visits (which would apply to the pre-operative visits and injections, not the surgery) and leaves you with excess charges. There is no network, no referral and no prior authorization, and you may choose any surgeon, any facility and any home health agency or skilled nursing facility that takes Medicare. The 221,009 Utahns in Original Medicare with no Medigap policy are the ones paying the figures in this article out of pocket, and for a knee with therapy that is well over two thousand dollars. Our Plan G versus Plan N and Medicare Advantage versus Medigap guides lay out the trade-offs.

A St. George example: one knee, home the next morning

Consider a 69-year-old retired schoolteacher in Washington County in Original Medicare. Her right knee has had two cortisone injections and a winter of physical therapy, and the X-ray shows bone on bone. One of the 20 orthopedic surgeons listed in St. George schedules a total knee replacement as an outpatient at the hospital, with one night of observation and discharge the next morning. Her daughter stays the first week, a home health therapist visits, and then she drives herself to outpatient therapy twice a week for four weeks. At 2024 Utah average surgeon's and therapy fees and the January 2026 national hospital outpatient rate, the Medicare-approved amounts look like this: