Yes, Original Medicare covers open heart surgery. Medicare Parts A and B often share the costs of single, double, triple, or quadruple coronary artery bypass surgery, aortic repair, or aortic replacement. Medicare will also help pay for cardiac rehabilitation programs, hospitalization, recovery drugs and equipment, catheterization, and stints.
When is Open Heart Surgery Necessary?
Open heart surgery is often essential to treat chronic heart failure, heart valve disease, arrhythmia, aneurysms, and coronary artery disease. It can also help restore blood flow around a clogged artery following a heart attack. Because open heart surgery is a major procedure, it is often a last resort and medically necessary.
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Understanding Medicare Coverage for Open Heart Surgery
Medicare coverage for open heart surgery depends on whether a patient has Original Medicare or Medicare Advantage, as well as Medigap.
Eligibility
A doctor must deem the procedure medically necessary for Medicare to cover any surgery. Considering their intensive nature, almost all open heart surgeries prove medically necessary and qualify for Medicare reimbursement.
Medicare Part A Coverage
Medicare Part A (hospital insurance) covers care and surgery expenses for patients in hospital settings. Part A will pay for the operation and Medicare-approved costs for hospitalized recovery time. Additional covered services include a semi-private room, medication, meals, and tests received in the hospital.
Medicare Part B Coverage
Medicare Part B (medical insurance) helps pay for outpatient care, doctors’ services, and durable medical equipment. Part B will cover non-hospital care and tests, doctor visits, and cardiac rehabilitation programs. If required, Part B will also pay for wheelchairs, crutches, or oxygen supplies needed for recovery.
Medigap Coverage
While Medicare Supplement Insurance (Medigap) does not directly help pay for open heart surgery, it will absorb some or all of your Part A and B deductibles, coinsurance, and copayments.
How Does Medicare Advantage Cover Open Heart Surgery?
All Medicare Advantage plans sold by private insurers must offer the same or better benefits than Original Medicare, including coverage for open heart surgery. Medicare Advantage may also provide additional services, such as low-cost post-operation prescription drugs, physical therapy, OTC allowances, and nutritional counseling to help avoid future heart concerns.
How Much Does Open Heart Surgery Cost With Medicare?
Out-of-pocket costs for open heart surgery vary depending on whether you seek coverage through Original Medicare or Medicare Advantage.
Part A Costs
After meeting your $1,632 Part A deductible, Medicare Part A will cover all the costs of inpatient hospital care, procedures, tests, and supplies. However, patients who stay in the hospital longer than 60 days will owe a $408 copayment for each additional day. These charges double to $816 for days 91-150. After 150 days, Medicare beneficiaries must pay for all other inpatient hospital care entirely out-of-pocket.
Part B Costs
Medicare Part B covers 80% of medically necessary care and outpatient doctors’ services. After paying your $174.70 monthly premium and $240 deductible, Part B charges a 20% coinsurance for the Medicare-approved cost of appointments, consultations, and durable medical equipment needed for open-heart surgery. Part B also covers 80% of open-heart surgery received in a hospital emergency room.
Medicare Advantage Costs
Medicare Advantage policies can set independent premiums and cost-sharing that vary greatly depending on medical network and location. While most Medicare Advantage plans charge fixed copayments for inpatient procedures like open heart surgery, some have a percentage-based coinsurance until a patient reaches their annual out-of-pocket maximum.
Alternatives to Open Heart Surgery
Because open heart surgeries are major procedures, seeking a second opinion is important. Some doctors may recommend less invasive alternative treatments, many of which would still qualify for Medicare benefits.
For example, transcatheter aortic valve replacement (TAVR) allows surgeons to insert new valves through small incisions in the legs or sternum, avoiding major trauma to the chest cavity. Similarly, through percutaneous coronary intervention (PCI), medical staff can install small tubes into blocked arteries to promote blood flow. If a doctor verified either procedure as medically necessary, Medicare would cover them equally to open heart surgery.
All in All
While invasive procedures like open heart valve repair and bypass surgery can prove costly without insurance, Medicare would cover much of the cost of any medically necessary or life-saving operation. Furthermore, Medicare can help pay for pre-surgery consultations, durable medical equipment, prolonged hospital stays, and most rehabilitation services required for recovery.
Considering the intensive nature of open heart surgery, it often proves wise to seek a second opinion. Some doctors may recommend TAVRs, PCIs, and other operations requiring less recovery time, money, and resources. Regardless of how you receive treatment, remember to call 1-800-MEDICARE or your private Medicare Advantage company beforehand to ensure you fully understand your benefits and coverage limitations.