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Medicare Hip and Knee Replacement Surgery in Sioux Falls 2026: What Part A, SNF Care, and Your Plan Actually Pay
Arthritis affects nearly 1 in 4 Minnehaha County adults — here is the complete 2026 cost map for joint replacement surgery, from the hospital bill to skilled nursing care to outpatient rehab.
The bottom line
- Arthritis affects 22.9% of Minnehaha County adults — one of the most prevalent chronic conditions in CDC local data, and the leading driver of hip and knee replacement surgery among Sioux Falls' 39,532 Medicare beneficiaries.
- Inpatient joint replacement triggers a $1,632 Part A deductible per benefit period; daily coinsurance is $0 for the first 60 hospital days.
- Skilled nursing facility rehab after surgery is $0 for days 1–20, then $204/day for days 21–100 — a gap Original Medicare does not cap.
- Medigap Plan G and Plan N both cover the $1,632 Part A deductible and the $204/day SNF coinsurance; Plan G also covers Part B excess charges, Plan N adds a $20 office-visit copay.
- All 5 Sioux Falls Medicare Advantage PPOs include an annual out-of-pocket maximum — protecting you when a surgical episode pushes costs higher than any single deductible suggests.
If you or a family member is facing hip or knee replacement on Medicare, the bill looks nothing like what most people expect. Original Medicare covers the surgery — but it leaves open a $1,632 deductible per benefit period, unlimited 20% outpatient coinsurance, and a $204/day skilled nursing facility cost that surprises almost every family. This guide maps every 2026 number using public CMS data so you can plan before you schedule, not after you get the bill.
All cost-sharing figures are from the CMS 2025 Medicare Parts A & B Premiums and Deductibles (Fact Sheet). Plan data is from the CMS Medicare Advantage / Part D Landscape (PY2026). Health prevalence data is from the CDC PLACES: Local Data for Better Health, County 2023. No invented numbers.
The Arthritis Burden in Minnehaha County
Arthritis is the primary driver of hip and knee replacement surgery nationwide. In Minnehaha County (Sioux Falls), it ranks among the top three chronic conditions tracked by CDC PLACES, affecting 22.9% of adults — and the Medicare population, which skews toward people 65 and older, carries a substantially higher arthritis burden than the adult average. Among Sioux Falls' 39,532 Medicare beneficiaries, arthritis-related joint deterioration is a common reason for surgical consultations at both Sanford and Avera.
Source: CDC PLACES: Local Data for Better Health, County 2023 (2023), model-based adult prevalence, Minnehaha County.
High blood pressure (31.7%) and obesity (37.4%) compound arthritis risk — both conditions accelerate joint degeneration and complicate surgical recovery. When the three conditions overlap in a single patient, the probability of eventually needing joint replacement rises meaningfully, making coverage planning especially important for Sioux Falls' Medicare population.
Key takeaway: Arthritis is the third-most-prevalent chronic condition in Minnehaha County — behind only high blood pressure and obesity, both of which also raise surgical risk and complicate recovery. If you or a family member has arthritis on Medicare, mapping the cost exposure before surgery can prevent a five-figure surprise after.
How Medicare Covers Joint Replacement Surgery
Medicare covers hip and knee replacement through two pathways, each with different cost-sharing rules and billing tracks:
| Surgery pathway | Medicare part | Your key cost-sharing | Typical setting |
|---|---|---|---|
| Inpatient admission | Part A | $1,632 deductible per benefit period; $0/day for days 1–60 after deductible | Hospital inpatient (admitted status) |
| Outpatient surgery | Part B | $257 annual deductible + 20% coinsurance (no annual ceiling under Original Medicare) | Outpatient hospital or ambulatory surgery center (ASC) |
Source: CMS 2025 Medicare Parts A & B Premiums and Deductibles (Fact Sheet).
CMS now permits total knee replacement at ambulatory surgery centers, and that trend has moved more procedures onto the Part B billing track. Whether your surgery is inpatient or outpatient depends on your surgeon's recommendation and your medical situation — the billing path is not always obvious in advance. Ask your surgeon's office before scheduling, because the billing track determines whether Part A or Part B cost-sharing applies, which in turn determines how your Medigap or Medicare Advantage plan responds.
The Inpatient Cost Math: Part A's $1,632 Deductible
For most inpatient joint replacements, the key number is the Part A deductible of $1,632 per benefit period. This is not an annual deductible — it resets each time you are hospitalized after a 60-day gap in inpatient care. A typical hip or knee replacement involves a 1-to-3-day hospital stay, so most patients pay the deductible once and owe nothing more for the hospitalization itself (days 1–60 carry no additional daily charge).
Extended stays are uncommon for routine joint replacement — but complications happen. If your stay reaches days 61–90, a $408/day coinsurance begins. After day 90, you draw from a pool of 60 lifetime reserve days at $816/day. Once those 60 days are gone, they are gone — Medicare pays nothing for days beyond them. A serious surgical complication can make extended-stay exposure very real for any beneficiary without supplemental coverage.
Skilled Nursing Facility Care After Surgery: The $204/Day Gap
Many patients — especially those recovering without a strong home-support network — transfer from the hospital to a skilled nursing facility (SNF) for post-surgical rehabilitation. This is where Medicare's cost structure surprises families most.
| SNF day range | Medicare pays | Your cost (Original Medicare) |
|---|---|---|
| Days 1–20 | 100% of approved amount | $0 |
| Days 21–100 | Balance after coinsurance | $204/day |
| Day 101 and beyond | $0 — Medicare stops | 100% (all costs on you) |
Source: CMS 2025 Medicare Parts A & B Premiums and Deductibles (Fact Sheet).
The SNF gap adds up fast. A patient who stays in the SNF through day 30 (paying $204/day for days 21–30, which is 10 days) owes $2,040 in SNF coinsurance alone — on top of the Part A deductible from the hospital stay. Combined, that brings the total exposure for a routine joint replacement with two weeks of SNF care to over $3,600 under Original Medicare, with no coverage for days 101 and beyond.
Two rules catch families off guard. First, Medicare requires a qualifying 3-day inpatient hospital stay before SNF coverage activates — observation stays do not count, even if you are physically in the hospital for three nights. Second, SNF coverage requires a clinical finding of "skilled care" need (active physical therapy, occupational therapy, or skilled nursing); custodial care alone does not qualify and is never covered by Medicare.
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Get your coverage map →Durable Medical Equipment: Walker, Crutches, and Home Aids
After hip or knee replacement, most patients go home with durable medical equipment: a walker or rolling walker, crutches, a raised toilet seat, or a shower chair. All of these fall under Part B DME coverage — the same benefit bucket as glucose monitors and home oxygen.
- $257 Part B annual deductible applies if it has not already been met for the calendar year
- 20% coinsurance of the Medicare-approved amount after the deductible
- Equipment must be medically necessary, physician-ordered, and obtained from a Medicare-enrolled DME supplier
Supplier assignment matters. A non-participating DME supplier can charge up to 15% above the Medicare-approved amount — an excess charge risk on top of the 20% coinsurance. In Sioux Falls, most major medical equipment suppliers accept assignment, but confirm before you rent or purchase. Medigap Plan G covers both the 20% coinsurance and any excess charges; Plan N covers the coinsurance but not the excess charge.
Outpatient Physical Therapy: No Annual Cap Since 2018
Post-surgical physical therapy is the foundation of joint replacement recovery. Medicare Part B covers outpatient PT, occupational therapy (OT), and speech therapy for any medically necessary reason — and Congress permanently eliminated the old annual therapy cap in 2018. There is no longer a set dollar limit on how much PT Medicare will approve, as long as care remains medically necessary and ordered by your physician.
The cost-sharing structure is the same as all other Part B outpatient services:
- $257 Part B annual deductible (once per year, shared across all Part B services)
- 20% coinsurance per approved PT visit — with no annual ceiling under Original Medicare
For a joint replacement patient, the deductible is likely already met by the surgery itself, so each subsequent PT session adds a 20% bill with no stop-loss. Under Medigap Plan G, the 20% coinsurance on every visit is covered in full after the $257 deductible. Under Plan N, the 20% is covered, but you pay a $20 copay per office visit. Medicare Advantage PPOs cap total annual exposure through their plan MOOP.
In Sioux Falls, outpatient PT is available at both Sanford Health and Avera Health outpatient rehab centers. Confirm that your plan covers the system where your surgeon practices for the smoothest post-surgical care coordination.
Medigap Plan G vs. Plan N: What Each Pays on a Joint Replacement
For beneficiaries on Original Medicare, Medigap (Medicare Supplement) plans are the primary tool for closing joint replacement cost gaps. Plan G and Plan N are the two standardized plans most commonly compared for people who became Medicare-eligible after January 1, 2020 (Plans C and F are no longer available to new enrollees).
| Coverage item | Plan G | Plan N |
|---|---|---|
| Part A deductible ($1,632 per benefit period) | Covered — $0 owed | Covered — $0 owed |
| Part A coinsurance, hospital days 61–90 ($408/day) | Covered | Covered |
| Part A lifetime reserve days ($816/day) | Covered | Covered |
| SNF coinsurance, days 21–100 ($204/day) | Covered — $0 owed | Covered — $0 owed |
| Part B coinsurance (20% on outpatient surgery, PT, DME) | Covered — $0 owed | Covered — $0 owed |
| Part B excess charges (up to 15% above Medicare rate) | Covered | Not covered |
| Office visit copay | $0 | $20 per visit |
| ER copay | $0 | $50 (waived if admitted) |
| Part B annual deductible ($257) | Not covered — you pay once | Not covered — you pay once |
Source: CMS — Choosing a Medigap Policy (Publication 02110); 42 CFR § 403.205.
Example cost scenario — inpatient joint replacement with 5 days in the SNF coinsurance window (days 21–25):
| Cost item | Original Medicare only | With Plan G | With Plan N |
|---|---|---|---|
| Part A deductible | $1,632 | $0 | $0 |
| SNF days 21–25 (5 days × $204) | $1,020 | $0 | $0 |
| Outpatient PT visits (20% coinsurance) | 20% of each approved visit — no ceiling | $0 | $20/visit copay |
| Part B annual deductible | $257 | $257 | $257 |
| Hospital + SNF gap (before PT) | $2,652 | $0 | $0 |
Both Plan G and Plan N eliminate the two biggest joint replacement gaps — the Part A deductible and the $204/day SNF coinsurance. Plan N adds a $20 per-visit copay for outpatient PT, which accumulates across a full post-surgical recovery course. Whether Plan G or Plan N is the better value depends on the premium difference available in your area and your expected PT utilization after surgery.
Medicare Advantage PPOs in Sioux Falls: How the MOOP Protects You
All 5 standard Medicare Advantage PPOs in Minnehaha County cover joint replacement surgery. The critical advantage over Original Medicare for major surgery is the annual out-of-pocket maximum (MOOP) — a ceiling on your total in-network costs per calendar year that Original Medicare does not provide. Once you hit the MOOP, your MA plan covers 100% of covered in-network costs for the rest of the year.
| Plan | Carrier | Monthly premium | Drug deductible | CMS Stars | Stability |
|---|---|---|---|---|---|
| Aetna Medicare Signature (PPO) | Aetna / CVS | $0 | $615 | 3.5★ | Average (3.5★) |
| Align ChoicePlus (PPO) | Sanford Health | $0 | $350 | 3.5★ | Average (3.5★) |
| Aetna Medicare Enhanced Extra (PPO) | Aetna / CVS | $52.00 | $615 | 3.5★ | Average (3.5★) |
| Align ChoiceElite (PPO) | Sanford Health | $66.00 | $300 | 3.5★ | Average (3.5★) |
| Blue Medicare Advantage Enhanced (PPO) | Wellmark / BCBS | $80.00 | $300 | 3.5★ | Average (3.5★) |
Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, 2026.
All 5 plans carry a 3.5-star CMS rating for 2026 — the average stability tier — meaning no local plan qualifies for the year-round 5-star Special Enrollment Period. For a joint replacement candidate, the premium alone does not tell you much: a $0-premium plan still exposes you to the plan's MOOP before coverage kicks in fully. Verify the specific annual MOOP for each plan on Medicare.gov or with a licensed agent, since plan-level MOOP amounts appear in each plan's Evidence of Coverage.
Key takeaway: A Medicare Advantage plan's annual MOOP is the single most important number to confirm before major surgery. Once your total in-network costs reach the MOOP, the plan covers 100% for the rest of the calendar year. Original Medicare has no equivalent protection — your 20% coinsurance exposure continues without any ceiling.
Sanford vs. Avera: Which Hospital System for Your Joint Replacement?
In Sioux Falls, the plan choice and the hospital choice are inseparable. Both major health systems perform hip and knee replacements and hold strong CMS quality ratings:
| Hospital | CMS Star Rating | System |
|---|---|---|
| Sanford USD Medical Center | ★★★★★ (5/5) | Sanford Health |
| Avera McKennan Hospital & University Health Center | ★★★★ (4/5) | Avera Health |
| Sioux Falls VA Medical Center | ★★★★★ (5/5) | U.S. Dept. of Veterans Affairs |
Source: CMS Hospital Compare — Overall Star Ratings.
Sanford USD Medical Center holds a 5-star CMS overall quality rating; Avera McKennan holds a 4-star — both are strong performers by national standards. The plan-to-hospital connection matters most here: Sanford's own Medicare plans (Align ChoicePlus and Align ChoiceElite PPO) are built around the Sanford network and may offer the most favorable in-network cost-sharing for Sanford-based orthopedic procedures. Aetna and Wellmark plans contract with both systems, but network depth varies year to year.
Always confirm that your specific orthopedic surgeon is in-network for the 2026 plan year before scheduling surgery — and confirm again during the Annual Enrollment Period (Oct 15–Dec 7) each fall, because network contracts renegotiate annually.
What to Watch for 2027
- Outpatient joint replacement expansion. CMS has steadily expanded ambulatory surgery center coverage for orthopedic procedures. Watch for whether total hip replacement joins total knee on the ASC-approved list — which would shift more surgery to the Part B billing track and change how Medigap and MA plans respond to your costs.
- Part A deductible adjustment. The $1,632 Part A deductible updates annually; CMS announces the 2027 figure in November 2026. If you are planning surgery near year-end, benefit-period timing around the deductible reset can reduce your total exposure.
- Plan network renegotiations. MA plans renegotiate hospital contracts each year. A plan that covered Sanford or Avera in-network for 2026 may change its network for 2027. Re-verify your surgeon is in-network during AEP (Oct 15–Dec 7) every fall.
- Prior authorization rule changes. CMS has issued rules limiting MA plan prior authorization practices. Confirm your plan's specific prior auth requirements for joint replacement before scheduling each plan year — requirements can change even if your plan renews.
- Star rating movement. All 5 Sioux Falls PPOs held 3.5 stars for 2026. CMS releases 2027 star ratings in October 2026 — check ratings during AEP, as a plan dropping below 3.0 stars faces CMS scrutiny and potential restrictions that could affect your coverage.
How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references the CMS cost-sharing fact sheet, the CMS plan landscape, CMS Hospital Compare, and CDC PLACES local health data — built by Strategic AI Architects. Every figure here is from a published federal dataset. This is education, not advice; confirm your coverage, costs, and eligibility with a licensed agent or Medicare.gov. We take no payment from any carrier to feature a plan.
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Frequently asked questions
Does Medicare cover hip and knee replacement surgery?
Yes. Medicare covers hip and knee replacement surgery through Part A (inpatient hospital) or Part B (outpatient/ambulatory surgery center). Under the inpatient path, you pay the Part A deductible of $1,632 per benefit period, then $0/day for the first 60 days. Under the outpatient path, you pay the $257 Part B annual deductible plus 20% of the Medicare-approved amount — with no annual ceiling under Original Medicare. Ask your surgeon's office which billing track applies before you schedule.
What does Medicare pay for skilled nursing facility care after joint replacement surgery?
Medicare Part A covers skilled nursing facility (SNF) care after a qualifying 3-day inpatient hospital stay. Days 1–20 cost you $0. Days 21–100 carry a $204/day coinsurance. After day 100, Medicare stops paying entirely. Medigap Plan G and Plan N both cover the $204/day SNF coinsurance for days 21–100. Medicare Advantage PPOs include an annual out-of-pocket maximum that limits your total SNF exposure each year.
Will Medigap Plan G or Plan N cover my costs for joint replacement surgery?
Both Plan G and Plan N cover the Part A deductible ($1,632) and the skilled nursing facility coinsurance ($204/day for days 21–100). Plan G also covers Part B excess charges; Plan N does not — though most Sioux Falls hospital systems accept Medicare assignment. Plan N adds a $20 copay per outpatient office visit and $50 per ER visit (waived if admitted). Your best choice depends on your expected utilization, drug costs, and the premium difference in your area.
Do Medicare Advantage PPOs in Sioux Falls cover joint replacement surgery?
All 5 standard Medicare Advantage PPOs in Minnehaha County are required to cover joint replacement surgery — all services Original Medicare covers must be covered. Each plan includes an annual out-of-pocket maximum (MOOP) that Original Medicare does not have, capping your total in-network exposure for surgery, SNF care, and recovery. The key Sioux Falls decision is network: Align plans (Sanford Health) and Aetna plans each favor different hospital systems. Confirm your surgeon and hospital are in-network for the 2026 plan year before scheduling.
Do I need a referral to see an orthopedic surgeon under Medicare in Sioux Falls?
Under Original Medicare, no referral is needed — you may see any Medicare-enrolled orthopedic surgeon directly. Under a Medicare Advantage PPO, referrals are generally not required for in-network specialists either. However, your plan may require prior authorization before the surgery is approved. Prior authorization requirements vary by plan; review your Evidence of Coverage or call your plan before scheduling to avoid unexpected denials.
Does Medicare cover physical therapy after hip or knee replacement?
Yes. Medicare Part B covers outpatient physical therapy after joint replacement at 80% of the Medicare-approved amount after the $257 annual deductible, leaving you responsible for 20% with no annual ceiling under Original Medicare. Congress eliminated the old therapy cap in 2018, so there is no set dollar limit on approved PT — as long as care is medically necessary and ordered by your physician. Medigap Plan G covers the 20% PT coinsurance in full; Plan N covers the 20% but adds a $20 office-visit copay per session.