Does Medicare Cover Open Heart Surgery?
Medicare covers open heart surgery, which is typically performed for coronary artery bypass surgery in the event of blocked heart arteries. It will also help cover cardiac rehabilitation after surgery. A Medicare Part D drug plan can pay part of the prescription drug costs you will incur after open heart surgery.
|Medicare Plan||Open Heart Surgery Coverage|
|Part A (Inpatient)||Covers surgery and Medicare-approved costs of your hospitalization after you have reached your Part A deductible. You are responsible for coinsurance costs for stays beyond 60 days.|
|Part B (Outpatient)||Covers 80% of non-hospital preoperative care costs and doctors visits, plus up to 36 cardiac rehab sessions over a period of up to 36 weeks, after you have reached your Part B deductible.|
|Part C (Medicare Advantage)||Covers everything covered by Medicare Part A and Part B. Select plans may offer additional benefits.|
|Part D (Prescription Drugs)||Covers related prescriptions including blood thinners, blood pressure medications and cholesterol-controlling drugs.|
|Supplemental Insurance||Can help cover out-of-pocket costs related to open heart surgery. Coverage varies by plan.|
Coverage for Open Heart Surgery
Original Medicare — Medicare Part A and Part B — covers most of the cost of open heart surgery. The procedure is often called bypass surgery, and it routes blood flow around blocked arteries in your heart.
- Medicare Part A hospital insurance
- Medicare Part A applies if you are admitted as an inpatient in a hospital setting. It covers the cost of your surgery and Medicare-approved costs of your hospitalization after you have paid your Part A deductible. You are responsible for coinsurance costs if you are hospitalized beyond 60 days. Covered services include a semi-private room, meals and medications you receive while in the hospital.
- Medicare Part B medical insurance
- Medicare Part B covers 80 percent of your non-hospital pre-operative care and tests, doctor visits and cardiac rehab after you have paid your Part B deductible. You are responsible for 20 percent of the Medicare-approved costs for medical services in addition to your deductible.
- Medicare Advantage plans
- Medicare Advantage plans are sold by private insurers and are required by law to cover everything Medicare Part A and Part B cover. But your policy may provide additional benefits. Most Medicare Advantage plans also include Medicare Part D prescription drug coverage. Check with your plan’s administrator about what your particular plan covers.
- Medicare Part D prescription drug plans
- Medicare Part D plans can help with the cost of prescription drugs you will need after open heart surgery. Each plan has its own Part D formulary — a list of prescription drugs it covers. Check with your plan’s administrator and your doctor to determine whether your prescriptions are covered. If they’re not, there may be an alternative drug that is covered.
- Medigap (Medicare Supplement) insurance
- Medigap policies are sold by private insurers and can help you cover your out-of-pocket costs if you have Original Medicare. Medigap policies cover all or part of your deductibles, copayments and coinsurance. Your plan’s administrator can tell you which costs you will still be responsible for.
Your Medicare plan may not specifically mention open heart or bypass surgery coverage. But Medicare covers procedures that a doctor or other medical specialist deems medically necessary. Open heart surgery generally meets the standard of being reasonable and necessary to protect a patient’s health and wellness.
Coverage for Cardiac Catheterization
Medicare also covers minimally invasive heart disease treatments that may be a viable alternative to open heart surgery. These laparoscopic surgeries use small incisions and with the surgeon using tubes and small instruments to repair the blockages.
These procedures are collectively called cardiac catheterization because they involve catheters inserted into the affected heart arteries.
- Balloon angioplasty uses a catheter to place a medical balloon into the blocked artery. The balloon is inflated, it opens the narrowed artery and improves blood flow. This procedure does not always result in long-term improvement.
- Similar to an angioplasty, a metal stent is inserted into the blocked artery. It is expanded, opening the blockage and holding the artery open for years or decades. This procedure can cause blood clots, which are often treated with prescription blood thinners.
Typically, cardiac catheterization is covered by Medicare Part B medical insurance. You are responsible for your Part B deductible. After that, Medicare pays 80 percent, and you pay 20 percent of the costs.
Medicare Part A hospital insurance covers the procedure if you’re admitted to a hospital and remain an inpatient through at least two midnights in a row during which the procedure is performed.
Doctors often prefer cardiac catheterization procedures over open heart surgery when possible. They tend to be less risky. But open heart surgery may be necessary in a cardiac emergency.
Medicare and Cardiac Rehab
Medicare Part B helps pay for cardiac rehabilitation after you have open heart surgery or other heart procedures. You are responsible for your Part B deductible, then Medicare will pay 80 percent of the cost and you will pay the remaining 20 percent.
Kaiser Health News reported in 2016 that the average out-of-pocket cost for people with Original Medicare was $20 per session, but that having a Medigap plan reduced that to zero. Copayments for people with Medicare Advantage plans ranged from zero to $60 per session. You should check with your plan’s administrator to see how much you may have to pay.
Medicare will pay for up to 36 cardiac rehab sessions over a period of up to 36 weeks. You can participate in up to two, one-hour sessions per day until you’ve completed the covered sessions. In certain cases, Medicare may cover an additional 36 sessions.
Open Heart Surgery Costs
Open heart surgery can be extremely expensive without Medicare or other insurance.
The Kaiser Family Foundation estimated that the average inpatient cost ranged from $75,688 to $117,000 in 2018 depending on complexity of the surgery and whether there were complications.
Original Medicare does not cover prescription drugs. But you can buy a Medicare Part D prescription drug plan. Most Medicare Advantage plans also include their own Part D plan.
These plans can help with the cost of prescription drugs you will have to take after your surgery, such as blood thinners, blood pressure medications and cholesterol-controlling drugs.
|Prescription Medication||Retail Price|
|Brilinta (ticagrelor)||$452–$504 per month|
|Plavix (clopidogrel)||$9–$114 per month|
|Coumadin, Jantoven (warfarin)||$4–$18 per month|
The monthly cost of statins — the go-to drugs for controlling cholesterol — can range from $29 for a generic to $430 for a brand name drug.
If you have a Medicare Advantage or Medicare Part D prescription drug plan, your choices may be limited by the plan’s formulary. Ask your plan administrator which drugs are covered, whether there are safe alternatives to a drug that isn’t covered under your formulary, and what your out-of-pocket costs will be.
6 Cited Research Articles
- McDermott, D. et al. (2020, November 4). How Costly Are Common Health Services in the United States? Retrieved from https://www.healthsystemtracker.org/chart-collection/how-costly-are-common-health-services-in-the-united-states/#item-start
- Appleby, J. (2016, August 31). Cardiac Rehab Improves Health, But Cost and Access Issues Complicate Success. Retrieved from https://khn.org/news/cardiac-rehab-improves-health-but-cost-and-access-issues-complicate-success/
- Roger, V.L. et al. (2011, February 1). Heart Disease and Stroke Statistics – 2011 Update; A Report from the American Heart Association. Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/cir.0b013e3182009701
- U.S. Centers for Medicare & Medicaid Services. (2019, July). Learning What Medicare Covers & How Much You Pay. Retrieved from https://www.medicare.gov/Pubs/pdf/11472-Learn-What-Medicare-Covers.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Cardiac Rehabilitation. Retrieved from https://www.medicare.gov/coverage/cardiac-rehabilitation
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Surgery. Retrieved from https://www.medicare.gov/coverage/surgery