The right plan could save you thousands of dollars

Heart disease is often linked to risk factors such as high blood pressure, high cholesterol, and smoking — and nearly half of Americans have at least one of these risk factors.

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Medical advancements have improved treatment options for heart problems, including medication and lifestyle education, but open heart surgery remains necessary for more complex cases, such as a bypass. It's expensive, however, ranging from $30,000 to $200,000, depending on the specifics.

Luckily for Medicare beneficiaries, heart surgery costs are taken care of. If you're enrolled in a Medicare Supplement Plan G, you could save thousands of dollars on open heart surgery. If you only have Original Medicare, you could receive up to 80% coverage but would be responsible for the remaining 20%.

This article will help you understand what's at stake financially when you're facing the possibility of open heart surgery — and how Medicare helps cover the costs.

What Is Open Heart Surgery?

Open heart surgery is performed to treat a variety of heart ailments. It involves making an incision in the chest to access the heart and its surrounding structures.

The surgery may be done to:

• Repair or replace damaged or diseased heart valves

• Repair or remove blockages in the coronary arteries

• Repair or replace a damaged or diseased heart muscle

When Do You Need Open Heart Surgery

You may need open-heart surgery if you have a heart condition such as:

• A congenital heart defect — problems with the heart that are present at birth, such as a hole in the heart (atrial septal defect)

• Coronary artery disease— a condition in which the coronary arteries become narrowed or blocked by plaque buildup

• Heart failure — when the heart is unable to pump enough blood to meet the body's needs

• Heart valve disease — when one or more of the heart's valves become narrowed, leaky, or otherwise damaged

• Thoracic aortic aneurysm — ballooning or dilation of the aorta

How Much Does Open Heart Surgery Cost?

The cost of open heart surgery varies depending on the facility, the surgeon and the type of surgery involved.

The most common types of open heart surgery can range from about $30,000 to over $200,000.

Procedures like blockage removal tend to be on the lower end of the cost spectrum, while heart bypass surgery and heart valve replacement typically fall in the middle to higher range. But, a heart transplant is significantly more expensive, costing $800,000 or more.

Does Medicare Cover Open Heart Surgery?

Yes.

Medicare generally covers open heart surgery or heart bypass surgery when it's medically necessary. This coverage also applies to any additional bypass surgeries, such as a double, triple, or quadruple bypass, as these are all lifesaving procedures.

Let's look at how different the Medicare parts cover open heart surgery.

Medicare Part A Coverage for Open Heart Surgery

Medicare Part A covers the cost of inpatient and hospital care, including heart surgeries.

After paying the Part A deductible of $1,600 (in 2023), Medicare will cover all expenses related to the surgery for the first 60 days of your hospital stay.

If your hospital stay exceeds 60 days, you will be responsible for additional costs as follows:

• Days 61-90: $400 coinsurance each day 

• Days 91 and beyond: $800 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to a maximum of 60 reserve days over your lifetime)

• Each day after the lifetime reserve days: All costs

Medicare Part B Coverage for Open Heart Surgery

Medicare Part B covers outpatient care, including preoperative care and follow-up appointments.

For open heart surgery, Medicare will cover 80% of the approved cost for outpatient care.

However, you’ll be responsible for paying:

• The Part B annual deductible — $226 in 2023

• 20% of the Medicare-approved costs

• Excess charges (if any)

Medicare Part B may also cover immunosuppressant drugs.

Medicare Part D Coverage for Open Heart Surgery

Medicare Part D plans help cover prescription costs related to open heart surgery, including blood thinners, blood pressure medications, and cholesterol-controlling drugs.

Each plan only covers the drugs listed in its formulary, so check with your plan provider and doctor to determine whether your specific prescriptions are covered. If not, ask your doctor for alternative drugs that are covered by your plan.

Medicare Advantage Plan Coverage for Open Heart Surgery

Medicare Advantage Plans offer the same coverage as Original Medicare, with some plans providing additional coverage for prescription drugs used to manage heart conditions.

Depending on your plan, you may have a fixed copay or a coinsurance amount that you'll pay until you reach your plan's out-of-pocket limit.

In case of a heart transplant, you may need to obtain prior authorization to get coverage.

Medigap Coverage for Open Heart Surgery

Medigap or Medicare Supplement Plans are insurance policies that supplement Original Medicare coverage and help pay for some out-of-pocket costs, such as deductibles, copays, and coinsurance. Medicare Supplement Plan G limits your out-of-pocket expenses to the Part B deductible of $226, so it's a wise choice to cover major surgery such as this.

Since Original Medicare covers open heart surgery, Medigap plans can help pay for the remaining 20% of costs not covered by Original Medicare, potentially reducing or eliminating your out-of-pocket expenses and preventing a cost pile-up.

Cardiac Rehabilitation

Cardiac rehabilitation is a medically supervised program that helps individuals recover from heart disease or heart-related surgery. The program typically includes exercise, education, and counseling to help improve cardiovascular fitness, reduce risk factors for heart disease, and improve overall health and quality of life.

Cardiac rehabilitation may include medication management, stress management techniques, and nutritional counseling.

The goal of cardiac rehabilitation is to help you return to an active and healthy lifestyle after a cardiac event or surgery.

How Long Does Medicare Pay for Cardiac Rehabilitation?

Medicare Part B covers 80% of the costs of a cardiac rehabilitation program if you’ve had at least one of these conditions:

• A heart attack in the last 12 months

• Coronary artery bypass surgery

• Current stable angina (chest pain)

• A heart valve repair or replacement

• A coronary angioplasty (a medical procedure used to open a blocked artery) or coronary stent (a procedure used to keep an artery open)

• A heart or heart-lung transplant

• Stable chronic heart failure

Medicare Part B also covers intensive cardiac rehabilitation programs in a doctor's office or outpatient setting (including a critical access hospital).

You'll still be responsible for:

• The Part B annual deductible — $226

• 20% of the Medicare-approved costs (if you receive these services in a doctor's office)

• A copayment (if you receive these services in a hospital outpatient setting)

Medicare covers cardiac rehabilitation for a maximum of 36 sessions, and if deemed medically necessary, patients may be eligible for additional coverage of 72 sessions, referred to as intensive cardiac rehabilitation.

Medicare Coverage is Complicated, but You Can Get Help

Medicare helps alleviate the cost of open heart surgery by covering both the procedure and the preoperative and post-operative care.

Medicare Part A covers the entire cost of open heart surgery for the first 60 days after the deductible is met. Medicare Part B and Part C help cover the cost of outpatient care and prescription drugs. Medicare Part B also covers your cardiac surgery rehabilitation.

Talk to your insurance provider to learn more about your specific plan coverage and whether your prescriptions are listed in your plan's drug formulary.

If you have any questions about your surgery or Medicare coverage, you can also speak with one of Fair Square Medicare's advisors at 1-888-376-2028. We're here to help.

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