According to the CDC, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. Cardiovascular health is a key component to maintaining good overall health, especially as we age. February is American Heart Month, serving as a yearly reminder to prioritize heart health and stay on top of routine, preventative care and treatments.
Before scheduling any checkups or procedures, it’s important to understand coverage provided by original Medicare as well as Medicare Advantage, and when supplemental plans may be necessary. Let’s dive in:
Both Medicare and most Medicare Advantage plans provide coverage for various cardiovascular health screenings that contribute to early detection and prevention.
Medicare Part B, which provides coverage for outpatient care, covers the following preventive services at 100% as long as your provider accepts assignment from Medicare:
These are covered once every five years and include blood tests for cholesterol, lipid and triglyceride levels that can help detect conditions that may lead to a heart attack or stroke.
A visit with a patient’s primary care doctor or other qualified practitioner in a primary care setting where the patient is provided counseling on reducing the risk for cardiovascular disease is covered once per year.
During this visit, the doctor will provide tips on maintaining a healthy heart through diet and exercise, take the patient’s blood pressure and discuss aspirin use, if appropriate. If the provider accepts assignment from Medicare, you will have any out-of-pocket costs.
Abdominal aortic aneurysm screening is an ultrasound that is covered once in a lifetime by Medicare Part B if the patient exhibits certain risk factors, including a family history of abdominal aortic aneurysms or if they’re a man between 65-75 who has smoked at least 100 cigarettes in their life, and has received a referral from a qualified provider. (You may want to suggest this to your spouse/partner!)
If more advanced screenings are required, including stress tests, nuclear stress tests, echocardiograms or EKGs, Medicare will provide coverage if they’re deemed medically necessary.
Medicare Advantage plans are required to provide the same coverage as Medicare, meaning they will provide coverage for the above preventive services, but there may be restrictions with doctor networks.
Heart disease can often lead to conditions like heart attack, stroke and heart failure, and/or the need for a heart procedure such as stents, an angioplasty or in severe cases, open heart surgery.
Medicare Part A will provide coverage for hospitalization due to a heart condition, heart attack, stroke, heart surgery and rehabilitation, but deductible and coinsurance costs will apply depending on the type of plan you have. Necessary and life-saving in-patient surgeries are also covered by Medicare Part A, which include heart bypass surgery and triple bypass surgery.
Medicare Part B can provide coverage for outpatient procedures that may be necessary including routine heart procedures like angioplasties, cardiac catheterizations, and stents.
Additionally, Part B will provide coverage for carotid artery stenting, but only with embolic protection that prevents embolism during endovascular procedures and if it takes place in a facility that meets CMS’s minimum standards and uses FDA-approved carotid artery stents and FDA-approved embolic protection devices. There are also specific requirements that need to be met in order for transcatheter aortic valve replacement (TAVR) to be covered by Part B.
If a heart transplant is required, original Medicare will provide coverage through a combination of Part A, which covers transplant service, tests, labs and exams, and Part B, which covers doctors’ services and immunosuppressive drugs, but the Part B deductible and 20% coinsurance applies. In order for Medicare Advantage to provide coverage, there needs to be prior authorization.
Original Medicare will also provide coverage for necessary medical devices including implantable automatic defibrillators and left ventricular assist devices. Whether Part A or Part B pays for the device, as well as associated out-of-pocket costs, depends on the circumstances surrounding the implantation, including diagnosis and whether it will be taking place in an in-patient or out-patient setting.
Following the diagnosis of heart disease and/or heart surgery, original Medicare and Medicare Advantage will cover cardiac rehabilitation if you meet their medical criteria and receive a referral from a provider. Cardiac rehab involves a combination of exercise, education, and counseling to assist with recovery, reduce risks and improve heart health.
Typically, cardiac rehab programs include up to 36 sessions following discharge, that can take place in a hospital, rehab facility or at home. Part B usually provides coverage for general rehab, which includes the 36 sessions, and if deemed medically necessary, will provide coverage for intensive cardiac rehab, which includes up to 72 sessions.
The Part B deductible applies, and additional out-of-pocket costs, including coinsurance and copays, will depend on if rehab services are given in a doctor’s office or hospital outpatient setting.
If medication is required as part of your treatment plan, Medicare Part B may provide coverage for some medications, including necessary immunosuppressive drugs following a heart transplant. However, most of the time, Medicare Part D or Medicare Advantage prescription drug plans will cover drugs used to treat heart conditions and symptoms, including anticoagulants, ACE inhibitors, beta-blockers, cholesterol-lowering medications, and diuretics.
While preventive services are usually covered in full by both Medicare and Medicare Advantage, diagnostic procedures and treatments include out-of-pocket costs that can add up pretty quickly. A supplemental plan, or Medigap, can protect you from any gaps in coverage and help cover out-of-pocket costs, including copayments, coinsurance, and deductibles, for anything Medicare covers. Medicare Supplement Plan G is a popular choice and is available to those enrolled in Medicare Part A and B.
Medigap can also help cover the monthly fee associated with Medicare’s chronic care management for those who are eligible, which includes beneficiaries with cardiovascular disease, high blood pressure or atrial fibrillation. This program provides a comprehensive care plan to help manage medications and coordinate care between healthcare settings.
For those with Medicare Advantage who are not eligible for Medigap, it’s worth looking into whether your provider offers a Medicare Advantage Special Needs Plan for chronic heart conditions, which can provide additional benefits and coverage for care specific to your needs.
Original Medicare and Medicare Advantage regularly update costs associated with and coverage provided by their respective plans, so it’s important to keep up with what services are covered and potential costs involved for cardiovascular care. If you have any questions or are unsure of what’s covered or not, don’t hesitate to ask your doctor or a trusted insurance professional!
Have you turned to Medicare for a heart related issue? Did you know exactly what to do or did you need to turn to a professional for guidance? What advice can you offer to our community?