Does Medicare cover heart valve repair surgery? 

According to the Centers for Disease Control and Prevention (CDC), about 2.5% of Americans have valvular heart disease. The condition is more prevalent in people born before 1943. Treatment varies with the level of severity. In some cases, your doctor may prescribe medication to manage the symptoms. In severe cases potentially leading to heart failure or cardiac arrest, you may require surgery.  

How does your heart valve affect function?

Your body is composed of hundreds of cells executing a myriad of functions to maintain life. For cells to thrive, your heart has to pump blood throughout your body, delivering nutrients and oxygen. The heart has four valves with two critical functions. The valves must open so blood can pass from the chamber and close correctly to prevent blood from going backward. A valvular heart condition is when a heart valve is damaged or diseased, disrupting normal blood flow.

Medicare coverage for surgery

If you require surgery to repair a heart valve, Medicare Part A would apply. Part A covers medically necessary inpatient hospital care. Coverage includes a semi-private room, three daily meals, general nursing services and drugs. Medicare also covers other hospital services and supplies essential to your inpatient treatment. Private rooms, private-duty nurses, television, phone and personal care items are not covered.

Medicare Part B covers medically necessary outpatient surgery in Medicare-approved hospitals. Coverage includes the cost of approved procedures and treatment services. Part B also covers 80% of the cost of physician services when you are an inpatient or outpatient.

Your out-of-pocket surgery costs

Your cost-sharing for Medicare-covered inpatient benefits includes the Part A deductible and, depending on the length of stay, it may include a daily copayment. The Part A deductible is due for each benefit period. A new benefit period begins after 60 consecutive days without inpatient care in a hospital or skilled nursing facility (SNF).

if you require a surgery or procedure in an outpatient setting, Part B would likely apply. For Part B benefits, you pay an annual Part B deductible, a monthly premium,  and 20% of the Medicare-approved amount. Additionally, hospital outpatient centers typically charge a copayment. The copayment can be as much as the Part A deductible.

How do Medicare Advantage plans cover heart valve repair surgery? 

Medicare Advantage (MA) members will have access to the same benefits included in Part A and Part B, but most will include more coverage. MA plans can require you to use a network healthcare provider in order for benefits to apply. Find benefit information in your MA plan summary and Evidence of Coverage (EOC). 

How do Medigap plans help cover heart valve surgery? 

Medicare Supplement (Medigap) insurance plans offer coverage to help fill in the gaps left by Origianl Medicare. Medigap plans vary in coverage of deductibles, coinsurance and copayments. If you have a Medigap plan, your Medicare-participating healthcare provider will bill Medicare first and then submit a claim to Medigap to pay any differential your policy covers. Please note, you cannot have both Medigap and Medicare Supplement.

Medicare coverage for cardiac rehabilitation

After your heart valve repair or replacement, you may need rehabilitation. Part B covers cardiac rehabilitation programs, which include exercise, education and counseling. You are responsible for 20% of the Medicare-approved amount after you fulfill the Part B deductible. If your rehab is in a hospital outpatient setting, a copayment may apply.

Medicare prescription drug coverage

Medicare Part D covers self-administered drugs your doctor prescribes for your heart condition. Each plan has a formulary you can reference to identify the prescriptions your plan covers. The formulary framework is usually tiers that reflect pricing. The higher the tier, the more costly the drug. If you have a financial need, contact the Extra Help program to see if you qualify for help paying for your heart medication.

Resources

The American Heart Association offers abundant information to help you learn about heart valve disease and repair surgery. Resources include fact sheets, checklists and tips in Spanish and English. Heart.org serves as a general guide for pre-surgery preparation, post-surgery recovery and treatment discussions with your doctor. For more details on valvular heart disease, visit the CDC website.