Questions to Ask Your Medicare Plan Before Knee Replacement

First, Know Which Type of Medicare You Have

The right questions depend on your coverage, so check your card before you call.

Original Medicare (Part A and Part B). Part A generally covers inpatient hospital care. Part B generally covers surgeon services, outpatient surgery, physical therapy, and medical equipment. You can see any doctor who accepts Medicare, usually without a referral or prior authorization. Many people add a Medicare Supplement (Medigap) policy to help with deductibles and coinsurance.

Medicare Advantage (Part C). These private plans must cover everything Original Medicare covers, but they often use provider networks, referral rules, and prior authorization. They also set an annual limit on out-of-pocket costs for covered services.

9 Questions to Ask Your Medicare Plan

1. Is my surgeon in network, and do I need a referral? With Original Medicare, ask whether your surgeon accepts Medicare. With Medicare Advantage, confirm the surgeon is in network. Some HMO plans also require a referral from your primary care doctor before you see a surgeon.

2. Does knee replacement require prior authorization? Many Medicare Advantage plans require approval before surgery. Ask who submits the request (often the surgeon’s office) and how long decisions typically take, so you can plan your surgery date.

3. Is the hospital or surgery center in network? The facility is billed separately from your surgeon, and so is anesthesia. Confirm all three are covered at the in-network rate.

4. Will my surgery be inpatient or outpatient, and how does that change my costs? Knee replacement may be performed as an inpatient, as an outpatient, or at an ambulatory surgery center, depending on your health and surgical plan. Inpatient care generally falls under Part A and outpatient care under Part B, with different cost sharing. Time spent under observation counts as outpatient. Some appropriate candidates may go home the same day.

5. Is my pre-surgery imaging covered? Robotic-assisted knee replacement with Mako technology often uses a CT scan to build a 3D model of your knee for surgical planning. Ask whether imaging needs separate approval and which in-network locations you can use.

6. How is physical therapy covered? Part B may cover medically necessary outpatient therapy. Medicare Advantage plans may require authorization or use of in-network therapists. Ask about your copay per visit, since physical therapy often involves several sessions a week. Also ask whether home health therapy is covered if you need it.

7. What medical equipment is covered? A walker or cane may be covered when prescribed and supplied by a Medicare-enrolled supplier (or an in-network supplier for Advantage plans). Some bathroom safety items may not be covered, so plan ahead when preparing your home.

8. Is a skilled nursing or rehab stay covered if I need one? Many patients recover at home, but it helps to know the rules. Original Medicare generally covers skilled nursing facility care only after at least 3 consecutive days as a hospital inpatient, not counting the discharge day. Medicare Advantage plans may have different rules and often require approval.

9. What will I pay in total? Ask about your deductible and your copays or coinsurance for the surgeon, facility, anesthesia, therapy, and prescriptions. With Medicare Advantage, ask about your out-of-pocket maximum. With Original Medicare, ask how your Medigap policy applies.

Timing Matters: Medicare Open Enrollment

If you are planning knee replacement next year, your plan choice matters. During Medicare Open Enrollment, October 15 to December 7, you can switch between Original Medicare and Medicare Advantage or change plans. Changes take effect January 1. People already enrolled in Medicare Advantage also have a second window, January 1 to March 31. Before choosing a plan, check whether your preferred surgeon and facility are covered.

Tips for Getting Clear Answers

• Call the number on your Medicare or plan card. Write down the date, the representative’s name, and a reference number for each call.
• Have details ready. Know the procedure name and your surgeon’s and facility’s names. Billing codes come from your surgeon’s office.
• Ask for answers in writing when possible, especially for prior authorization decisions.
• Bring your notes to your consultation so you and the care team can plan around your coverage. Here is what to expect at your knee replacement consultation.

This article is for general information only and is not insurance advice. Coverage varies by individual plan. Please confirm your benefits directly with your Medicare plan.