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Does Medicare Cover Open-Heart Surgery?

Did you know that, each year, over two million people worldwide undergo open-heart surgery? This common and incredibly invasive surgery can require more recovery time than other surgeries, even other heart surgeries. And its complexity can lead to high costs.

It’s helpful to understand what open-heart surgery is, especially if one is necessary for you. Similarly, if you have Medicare, it’s important to know whether your open-heart surgery and the services connected to it are covered by your Medicare plan.

What is Open-Heart Surgery?

A heart surgery is a surgery done directly on the heart muscle or any of the adjoining valves, arteries, or aorta. Open-heart surgery occurs when the heart is accessed directly by opening the sternum and may be used to redirect blood flow from a blocked artery to the heart in a procedure called a coronary artery bypass grafting (CABG, pronounced cabbage). Open-heart surgery may also be used to repair heart valves, sections of the heart organ, implant a device, or perform a heart transplant.

There are two types of open-heart surgery — on-pump and off-pump. Off-pump is where the heart is still beating; this is only used for a CABG. On-pump open-heart surgery is any heart surgery where your heart is actually stopped, and your body is connected to a heart-lung bypass machine or pump. This machine does the work normally done by your heart while the surgeons work on the organ.

When you undergo an open-heart surgery, you’ll receive anesthesia. Once you’re asleep, the surgeon will make a six- to eight-inch-long incision on your chest. They’ll then cut your sternum and open your ribcage to access the heart. At this point, you’ll be attached to a machine if it’s an on-pump surgery. After the repairs are made, you’ll be disconnected from the machine, restoring normal function to your circulatory system if you were on a pump. Your chest will be closed with wires or sutures before your skin is stitched back together.

What Does It Cost?

With such complexity, it’s no surprise that open-heart surgeries can rank among the most expensive procedures. While prices can range depending on a number of factors, the average cost of a bypass surgery is $123,000, while a heart valve replacement is $170,000. A CABG ranges from $44,824 to $448,038. These are not small fees by any stretch of the imagination.

Does Medicare Cover Open Heart Surgery?

As long your procedure is medically necessary, which it most likely will be, your open-heart surgery will probably be covered by Original Medicare. Since this type of surgery will almost certainly be given in an inpatient setting, it’ll likely be covered by Medicare Part A. This means that you’ll first need to meet your inpatient hospital deductible ($1,600 in 2023). After that, you’ll have a $0 copayment until day 61 of your hospital stay, if you’re still there. After that, you’ll owe a daily coinsurance for days 61 to 90 of your stay ($400 in 2023). After day 90, you’ll use your lifetime reserve days ($800 in 2023) if they’re needed and still available.

You may be able to reduce your out-of-pocket costs further by enrolling in a Medicare Supplement that covers Part A coinsurances or the Part A deductible. Some Medicare Advantage plans may also offer additional coverage.

Does Medicare Cover Recovery?

Recovering from open-heart surgery can be a long road, usually requiring four to five days of hospital stay and another six to eight weeks of recovery, but exact times vary based on your personal situation. It won’t always be easy, but at the very least, Medicare can help you afford it. Your hospital stay should be covered under Medicare Part A, just like your surgery. Once you’re out of the hospital, your recovery should still be covered by Medicare under Part B’s outpatient coverage, after meeting your Part B deductible ($226 in 2023).

Depending on why you needed surgery, Medicare may also cover a comprehensive cardiac rehabilitation program. These conditions are:

  • Heart attack in the last year
  • Coronary artery bypass surgery (another name for CABG)
  • A current stable angina (chest pain)
  • Heart valve replacement or repair
  • Coronary angioplasty or stent
  • Heart or heart-lung transplant
  • Stable chronic heart failure

When you receive these services at a doctor’s office, you’ll only owe 20 percent of the Medicare-approved amount unless you have supplemental insurance, which can help cover this remainder. Outpatient services provided in a hospital setting will also have a copayment.

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Open-heart surgery is a major surgery and for a good reason. Whether it’s with a pump or without one, you can expect there to be a lot of recovery needed. If you don’t have insurance, you may bear the weight of serious medical costs adding to that burden, but with Medicare, many of your expenses can be covered. Whatever type of coverage you have, Medicare can make affording a medically necessary heart surgery possible.

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