Does HSS Accept Medicare? What You Need to Know

Yes, HSS accepts Medicare, but coverage depends on your specific plan

Hospital for Special Surgery (HSS) is an in-network provider for most Medicare Advantage plans and Original Medicare in the New York area. However, whether HSS covers your care depends on which Medicare plan you have, which specific service you need, and whether your doctor refers you there. Not every HSS location or service is covered the same way, and some treatments may require prior approval from your plan before you go.

If you have Original Medicare (Part A and Part B), HSS will accept it as long as your doctor is in-network or you are referred by an in-network provider. If you have a Medicare Advantage plan, you need to check whether HSS is listed as in-network for your specific plan — coverage varies by plan and by year.

Key Takeaways

HSS accepts Original Medicare and most Medicare Advantage plans in the New York area, but you should confirm your plan covers the specific service you need before scheduling.
Some treatments at HSS require prior approval from your Medicare plan before the appointment, and going without approval can mean you pay more out of pocket.
Your out-of-pocket cost depends on whether you have Original Medicare or a Medicare Advantage plan, and whether the service requires a copay, coinsurance, or deductible.
Call HSS directly at their patient access line or contact your Medicare plan to confirm coverage before your first visit.

How to check if your Medicare plan covers HSS

The fastest way to confirm coverage is to call HSS directly and give them your Medicare card number. HSS has a patient access team that can look up your plan in their system and tell you whether you are covered, what your out-of-pocket costs will be, and whether you need prior approval for your specific procedure or service.

You can also contact your Medicare plan directly — the phone number is on the back of your Medicare card. Tell them you want to see HSS and ask whether HSS is in-network for your plan. If you have a Medicare Advantage plan, ask specifically whether the service you need (for example, orthopedic surgery or physical therapy) is covered at HSS.

If HSS is not in-network for your plan, you can still go there, but you will likely pay more. Out-of-network care under Original Medicare means you pay 20% of the approved amount after your deductible. Under a Medicare Advantage plan, out-of-network care may not be covered at all, or you may pay the full bill.

What you need to bring to your HSS appointment

Bring your Medicare card and any other insurance cards you have. If you have a Medicare Advantage plan, bring that card too — some people have both Original Medicare and a supplemental plan, and HSS needs to know the order in which to bill them.

Bring a photo ID and any referral paperwork from your doctor. If your plan requires prior approval and you have already received it, bring that approval letter or the approval number. HSS will ask for your emergency contact and medical history, so you can fill out those forms online before your visit to save time.

Prior approval and when you need it

Some Medicare plans require prior authorization before you have certain procedures or see a specialist. This means your doctor's office or HSS must contact your plan and get written approval before your appointment. If you do not get prior approval when it is required, your plan may deny the claim, and you could be responsible for the full cost.

Common services that often need prior approval include surgery, advanced imaging (like MRI or CT scans), and certain physical therapy programs. Your doctor's office usually handles this, but you can ask them to confirm that approval has been received before you go to HSS.

If you are unsure whether your service needs prior approval, call your Medicare plan and ask. They can tell you in one call whether approval is required and how long it usually takes to get it.

Out-of-pocket costs at HSS under Medicare

Your costs depend on your plan type. Under Original Medicare, you pay a $226 Part B deductible per year (this amount changes yearly), then 20% coinsurance for most services after that. For hospital stays, you pay a Part A deductible of $1,676 per benefit period (this also changes yearly). HSS will bill Medicare first, then send you a bill for your share.

Under a Medicare Advantage plan, your costs are usually lower — you might pay a copay of $20 to $50 per visit or a percentage of the cost, depending on your plan. Some plans have an annual out-of-pocket maximum, which means once you reach that amount, the plan covers 100% of in-network care for the rest of the year.

If you have a Medigap supplemental plan (also called Medigap insurance), it may cover some or all of your Original Medicare coinsurance and deductibles. Tell HSS if you have Medigap so they can bill it after Medicare pays.

What to do if HSS is out-of-network for your plan

If HSS is not in-network for your Medicare Advantage plan, you have a few options. First, ask your plan whether they have an out-of-network coverage benefit — some plans do cover out-of-network care, though usually at a higher cost to you. Second, ask your doctor whether there is an in-network orthopedic or specialty hospital in your area that can provide the same care.

Third, you can request a continuity of care exception from your Medicare Advantage plan if you were already seeing an HSS doctor before you switched plans. Some plans will cover ongoing care with an out-of-network provider for a limited time if you were established there. Call your plan and ask whether this is an option.

If none of those work and you decide to go to HSS anyway, ask HSS to give you an estimate of your out-of-pocket cost before your visit. This is called a Good Faith Estimate, and HSS is required to provide it if you ask.

Frequently Asked Questions

Do I need a referral from my doctor to see someone at HSS?

It depends on your plan. Original Medicare does not require a referral for most specialists. Many Medicare Advantage plans do require a referral, especially to see an orthopedic surgeon or other specialist. Check your plan documents or call your plan to find out whether you need one before you call HSS to schedule.

Will HSS bill my Medicare plan directly?

Yes. HSS will submit the bill to Medicare (or your Medicare Advantage plan) directly. You do not have to submit anything yourself. You will receive an explanation of benefits from Medicare or your plan showing what they paid and what you owe.

What if I have both Original Medicare and a Medicare Advantage plan?

You should have only one at a time. If you have both, tell HSS which one is your primary plan. If you recently switched plans, make sure your old plan has been cancelled to avoid billing confusion. Contact Medicare at 1-800-MEDICARE if you are unsure which plan is active.

Can I use my Medicare to see an HSS doctor at a location outside New York?

HSS has locations in New York and New Jersey. Medicare coverage at HSS locations outside the New York area may be different. Call HSS or your Medicare plan to confirm coverage before you travel for an appointment at a different location.

What happens if HSS bills me and I think the amount is wrong?

Contact HSS patient billing first and ask them to review the charge. If you still disagree, you can file an appeal with your Medicare plan. Your explanation of benefits will show you how to appeal. Keep copies of all bills and correspondence.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.