Turning 65 and considering hip or knee replacement? Learn how Medicare enrollment, coverage start dates, and Medigap timing can affect your surgery plans.
For many people, hip or knee arthritis starts to limit daily life in their early to mid-60s, right as Medicare enters the picture. If joint replacement is in your near future, a little planning can help your transition to Medicare go smoothly.
Considering hip or knee replacement in Palm Beach County? Robert J. Avino, M.D., is a board-certified, fellowship-trained orthopedic surgeon who has performed 1,400+ robotic-assisted hip and knee replacements. Request a consultation or call (561) 694-7776 and ask for Dr. Avino.
Medicare Enrollment Basics at 65
Your Initial Enrollment Period lasts 7 months. It starts 3 months before the month you turn 65 and ends 3 months after it.
When you sign up affects when coverage starts. If you sign up before your birthday month, Part B coverage starts the first day of that month. If you sign up during your birthday month or later, coverage starts the first day of the following month. Premium-free Part A generally starts the month you turn 65.
Some people are enrolled automatically. If you already receive Social Security benefits, you will generally be enrolled in Part A and Part B automatically.
Still working? If you have health coverage through your own or your spouse’s current employer, you may be able to delay Part B without a penalty. You would then have 8 months to sign up after that employment or coverage ends. COBRA and retiree coverage generally do not count as current employer coverage for this purpose, so ask your benefits office how your plan works with Medicare.
Surgery Before or After 65? Factors to Weigh
There is no single right answer. These are the factors many patients consider:
- Medical readiness. If arthritis is already limiting your walking, sleep, or activities, waiting several months only for insurance reasons can mean more time with pain and lost activity. Read when it may be time for knee replacement or hip replacement.
- Your current deductible and out-of-pocket maximum. If you have already met them this year, surgery under your current plan may cost less. If not, compare that with your expected Medicare cost sharing.
- Dates close to your Medicare start. Coverage is based on the date of each service. If surgery occurs just before your switch, recovery care, such as physical therapy, may be billed to your new coverage.
- Prior authorization. Approval from your current insurer generally does not carry over to a new plan. A Medicare Advantage plan may require its own authorization before surgery.
- Continuity of care. Confirm that your surgeon, hospital or surgery center, and physical therapist accept Medicare or are in network with the plan you choose.
Choosing Medicare Coverage With Surgery Ahead
The right coverage depends on your health, budget, and preferred doctors. Knowing surgery may be coming can shape what you look for.
Original Medicare with a Medigap policy. You can see any doctor who accepts Medicare, generally without a referral or prior authorization, for knee or hip replacement. A Medicare Supplement (Medigap) policy may help pay deductibles and coinsurance.
Timing matters here. Your Medigap Open Enrollment Period lasts 6 months, starting the first month you have Part B and are 65 or older. During that window, insurers cannot deny you coverage or charge you more because of health conditions like arthritis. After it ends, insurers in most states may use medical underwriting, and you could be denied or pay more. If you did not have continuous health coverage before Medicare, a policy may delay coverage for pre-existing conditions for up to 6 months.
Medicare Advantage. These plans must cover everything Original Medicare covers and include an annual out-of-pocket limit. They often use provider networks and prior authorization. Before enrolling, confirm that your surgeon and preferred facility are in-network.
Prescription coverage. Whichever path you choose, consider Part D or a plan that covers medications during recovery.
A Planning Checklist
- Mark your Initial Enrollment Period dates on your calendar, along with your 6-month Medigap window if you choose Original Medicare.
- Talk with your surgeon about readiness and timing before making coverage decisions around a surgery date.
- Call your current insurer to ask what remains on your deductible and out-of-pocket maximum this year.
- Confirm your care team accepts your new coverage, including your surgeon, facility, and physical therapist.
- Ask about any new plan’s prior authorization and how long approvals typically take.
- Get free, unbiased help. Florida’s SHINE program (Serving Health Insurance Needs of Elders) offers free one-on-one Medicare counseling through the Elder Helpline at 1-800-963-5337. You can also call 1-800-MEDICARE.
Plan Your Joint Replacement With Confidence
A consultation can help you understand whether hip or knee replacement may be right for you, and when. Robert J. Avino, M.D., completed fellowship training in adult hip and knee reconstruction at Cleveland Clinic and has performed 1,400+ robotic-assisted hip and knee replacements in Palm Beach County using Mako technology. Learn more about Medicare and Dr. Avino’s practice or view all accepted insurance plans.
Ready to start planning? Request a consultation or call (561) 694-7776 and ask for Dr. Avino.
Schedule a Consultation Today
If hip or knee pain is slowing you down, don’t wait. Request a consultation online or call
Palm Beach Orthopedic Institute and ask for Dr. Robert J. Avino.