Does Medicare Cover 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.

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.

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.

Typically, cardiac catheterization is covered by Medicare Part B medical insurance. You are responsible for your Part B deductible. After that, Medicare pays 80%, and you pay 20% 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 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% of the cost and you will pay the remaining 20%.

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 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.

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.