Does Medicare Cover Open-Heart Surgery?

If you’re staring down the words “open-heart surgery”, your brain is probably doing two things at once:
(1) worrying about your actual heart, and (2) worrying about your bank account. Totally normal. The good news:
Medicare generally does cover open-heart surgery when it’s medically necessary and performed at a facility
(and by clinicians) that accept Medicare. The not-so-fun news: coverage and costs depend on which kind of Medicare
you have and whether your care is billed as inpatient or outpatient/observation.
And yes, those words can change what you pay. ^[1][2]

This guide breaks it all down in plain EnglishOriginal Medicare vs. Medicare Advantage, what Parts A/B/D actually pay for,
what you might owe in 2026, and how to dodge surprise bills like you’re Neo in The Matrix (but with more paperwork).

Quick answer: YesMedicare covers open-heart surgery (most of the time)

Under both Original Medicare and Medicare Advantage, medically necessary hospital and physician services
are covered. Medicare Advantage plans are required to cover the same medically necessary services that Original Medicare covers,
though the rules of the road (networks, prior authorization, cost-sharing) can differ. ^[6]

What counts as “open-heart surgery” (and why Medicare cares)

“Open-heart surgery” is a broad, real-world phrase, not a single billing code. It generally refers to surgery where the chest is opened
to repair or treat heart conditions. Common examples include:

• Coronary artery bypass grafting (CABG) (a “heart bypass”) ^[11]
• Heart valve repair or replacement ^[7]
• Heart transplant and other major cardiac procedures (depending on diagnosis and eligibility) ^[12]

Medicare doesn’t decide coverage based on whether something sounds dramatic (though “open-heart” definitely does).
Coverage is typically about whether the procedure is medically necessary, performed in an appropriate setting,
and billed under covered benefits. ^[5]

How Original Medicare pays for open-heart surgery

Original Medicare is basically a two-part tag-team for major surgery: Part A covers the hospital “big stuff,” and
Part B covers the professional and outpatient side. Then Part D (if you have it) may help with many
take-home prescriptions.

Part A: the hospital side (usually the biggest chunk)

If your surgery requires being formally admitted as an inpatient, Part A generally covers inpatient hospital services.
Medicare measures inpatient hospital use in benefit periodsa benefit period begins the day you’re admitted as an inpatient
and ends when you haven’t received inpatient hospital care (or skilled care in a SNF) for 60 days in a row. ^[1]

In plain terms: if you’re admitted for open-heart surgery and recover in the hospital as an inpatient, Part A is the primary payer for the
facility charges. You’ll typically see Part A associated with things like your room, meals, nursing, operating room services, labs, imaging,
and medications provided as part of your inpatient stay. ^[2]

Part B: the people who walk into your room…and bill separately

Even during an inpatient hospital stay, doctors’ services are generally billed under Part B. Medicare notes that if you have Part B,
it generally covers 80% of the Medicare-approved amount for doctors’ services you get while you’re in a hospital. ^[1]
After you meet the Part B deductible, you generally pay 20% of the Medicare-approved amount for covered physician services. ^[2]

For open-heart surgery, Part B commonly includes charges from the surgeon, assistant surgeon (if applicable), anesthesiologist, cardiologist,
radiologist, pathologist, and other clinicians involved in your care. It can also include outpatient follow-ups, cardiac rehab, durable medical
equipment, and certain home health services (depending on your situation). ^[3][5]

Part D: prescriptions after the hospital, plus a surprise category

After open-heart surgery, your medication list might get longer (temporarily or permanently). Many prescriptions you pick up at the pharmacy are
typically covered under Part D (if you have a Part D plan).

There’s also a sneaky category Medicare talks about: “self-administered drugs” in outpatient settings.
Part B generally doesn’t cover most outpatient prescription/over-the-counter drugs you’d normally take yourself, and Medicare notes you may end up paying
out of pocket and then submitting a claim to your drug plan in certain circumstances. Translation: if your status is outpatient/observation, drug billing can
feel like a plot twist. ^[4][2]

Inpatient vs. observation: two words that can change your bill

Here’s the part nobody frames and hangs on the wall, but everyone should understand:
you can spend the night in a hospital and still be considered an outpatient.
Medicare explains that you’re an inpatient starting when a doctor writes an order formally admitting you, and you’re an outpatient if you’re getting
services like observation or outpatient surgery and the doctor hasn’t written an inpatient admission ordereven if you stay overnight. ^[2]

Open-heart surgery is typically inpatient, but the days before surgery or certain complications can involve observation status.
Why it matters:

• Cost-sharing can differ (Part A inpatient deductible vs. Part B copays/coinsurance).
• Post-acute coverage, especially skilled nursing facility (SNF) eligibility, can be affected because SNF coverage often depends on an inpatient hospital stay. ^[8]

What you might pay in 2026 (real numbers, but they can change)

Medical billing is the only place where “benefit period” sounds like a spa package and absolutely is not.
Here are the big-picture Medicare cost-sharing pieces that commonly come into play for open-heart surgery.

Part A inpatient hospital costs (2026)

For an inpatient hospital stay, the Part A inpatient hospital deductible is $1,736 in 2026.
That deductible covers your share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. ^[3]

If your hospital stay is longer, additional coinsurance can apply. In 2026, CMS lists:
$434/day for days 61–90 and $868/day for lifetime reserve days. ^[3]
(Most open-heart surgery stays don’t run that long, but complications happenso it’s worth knowing the rules.)

Part B costs (2026)

In 2026, CMS lists the standard Part B premium as $202.90/month and the Part B annual deductible as
$283. After you meet the deductible, Part B commonly involves 20% coinsurance for covered services (based on the Medicare-approved amount). ^[3][2]

Why “20%” can still be a big deal

Open-heart surgery involves high-cost professional services. Even though Medicare-negotiated rates are typically lower than sticker prices,
20% of a big number is still a number you notice. This is one reason people pair Original Medicare with a Medigap policy
or have other secondary coverage.

Medicare Advantage (Part C): covered, but with plan rules

Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. ^[6]
However, the experience often looks different from Original Medicare:

• Networks: Your plan may require in-network hospitals and surgeons for the lowest cost (or for coverage, depending on the plan type).
• Prior authorization: Many plans use prior authorization for certain servicesespecially non-emergency or post-acute careso paperwork can matter.
• Cost-sharing: Instead of a Part A deductible + Part B 20%, you may see per-day hospital copays, procedure copays, and different rehab cost-sharing.
• Out-of-pocket maximum: Medicare Advantage plans have annual out-of-pocket limits for Part A and Part B services (Original Medicare alone does not). ^[13]

Practical takeaway: with Medicare Advantage, open-heart surgery is usually covered, but you want to confirm the hospital system,
the cardiac surgeon group, and the anesthesia team are treated as in-network (or covered) before you show up
in a gown that opens in the back.

The add-ons that can protect your wallet

Medigap (Medicare Supplement) with Original Medicare

Medigap policies can help pay some of the “gaps” in Original Medicarelike coinsurance and certain deductiblesdepending on the plan letter.
Medicare’s Medigap comparison notes that Medigap generally pays coinsurance after you’ve paid the deductible (unless your Medigap plan also covers the deductible). ^[10]

Translation: if you have Original Medicare and you’re worried about the Part A deductible and Part B 20% coinsurance on a major surgery,
Medigap is one of the most common ways people reduce surprise costs.

Medicaid or other secondary insurance

If you qualify for Medicaid (or have retiree coverage, union coverage, etc.), that secondary coverage may reduce or eliminate certain Medicare
cost-sharing. Rules vary by program and state, but it’s worth asking before surgery day.

After surgery: rehab, skilled nursing, home health, and follow-ups

Open-heart surgery isn’t a “one-and-done” event. Recovery includes follow-ups, medication management, and often rehab. Medicare coverage usually extends
into these phases, but each piece has its own rules.

Cardiac rehab (often a game-changer)

Medicare Part B covers regular and intensive cardiac rehabilitation programs. Medicare lists eligibility conditions that include
coronary artery bypass surgery and heart valve repair or replacement, among others. Costs typically include
20% coinsurance (and in a hospital outpatient setting, you may also pay a hospital copayment); the Part B deductible applies. ^[7]

Skilled nursing facility (SNF) care

Some people need a short SNF stay after hospitalization. Medicare’s SNF coverage page notes the common “3-day rule,” and also notes there are situations
where the 3-day minimum inpatient stay may not be required due to certain waivers or Medicare initiatives, and that Medicare Advantage plans may also waive
the 3-day minimum. ^[8]

Bottom line: if SNF is on the table, ask the discharge planner whether your hospital days are counted as inpatient and whether you meet
Medicare’s SNF eligibility rules.

Home health services

Medicare covers certain home health services if you’re eligible, and Medicare’s home health page notes these services can be covered by Part A or Part B
and that you generally pay nothing for covered home health services (though other costs may apply). ^[9]

A checklist to reduce surprise bills (your “future self” will thank you)

1. Confirm your status: Ask, “Am I being admitted as an inpatient?” Get clarity early. ^[2]
2. Verify the facility takes Medicare: For Original Medicare, services are typically covered at hospitals that take Medicare. ^[1]
3. Ask if clinicians accept assignment: For Part B, assignment affects how billing works and what you may owe. ^[1]
4. If you have Medicare Advantage: Confirm in-network status and whether prior authorization is required.
5. Get a cost estimate: Hospitals must post standard charges, and many provide estimates on requestuse that info to plan ahead. ^[1]
6. Plan the “after”: Cardiac rehab, home health, and possible SNF careknow what’s covered and what rules apply. ^[7][8][9]
7. Medication reality check: Ask which meds are billed under Part B vs. Part D, especially if observation/outpatient status is involved. ^[4]

The bottom line

Yes, Medicare covers open-heart surgery in the way most people mean ithospitalization, surgeon services, anesthesia, tests,
and medically necessary follow-upso long as the procedure is covered and medically necessary. Under Original Medicare, the biggest split is
typically Part A for the inpatient hospital stay and Part B for physician/professional services. Under Medicare Advantage,
coverage is still there, but it’s filtered through plan rules like networks and prior authorizations. ^[6][1]

The smartest move is to treat open-heart surgery like a two-part project: health plan + billing plan.
Your heart team handles the first one. This article helps you handle the secondwithout needing a minor in administrative law.

Experiences related to “Does Medicare Cover Open-Heart Surgery?” (the “real-life-ish” edition)

The facts are important, but so is what it feels like to live through the Medicare side of open-heart surgery. Below are composite, real-world-style
experiencescommon scenarios that help people understand what happens between “Your surgery is scheduled” and “Why did I get seven bills for one heart?”

Experience #1: The “Original Medicare + Medigap = fewer surprises” story

One common experience is a person with Original Medicare who also carries a Medigap plan. The surgery happens in a Medicare-participating hospital, the stay
is clearly inpatient, and bills arrive in a neat(ish) sequence: the hospital claim runs through Part A, and the surgeon/anesthesiology/cardiology claims run
through Part B. The patient still sees the numbers on the statements, but the out-of-pocket amount is noticeably lower because secondary coverage picks up
some of what Medicare doesn’t pay. The emotional tone of this experience is basically: “I’m stressed about recoverybut at least my mailbox isn’t scary.”

Experience #2: The Medicare Advantage “network detective” phase

Medicare Advantage experiences often begin before surgery with what I call “network detective work.” The hospital might be in-network, but the
cardiothoracic surgeon is part of a separate physician group. The anesthesiology team might be contracted separately too. People who do best in this situation
ask pointed questions early: “Is the surgeon in-network? What about anesthesia? What about the assistant surgeon?” It feels a little ridiculous to be doing
insurance math while contemplating a bypass, but it can prevent major cost shocks.

After surgery, Medicare Advantage members often appreciate the predictability of an annual out-of-pocket maximum, but they may encounter prior authorization
steps for rehab or post-acute services. The lived experience can be: “Great care, lots of phone calls, keep a notebook.”

Experience #3: The observation-status curveball

Another scenario: someone goes to the ER with chest symptoms, gets monitored, and spends a night or two in the hospital prior to a procedure.
They assume “overnight = inpatient.” But the paperwork says “observation.” Later, they learn that observation is outpatient status and can change which Medicare
rules apply. This can create confusion about copays, medication billing, and especially whether the hospital stay counts toward SNF eligibility if rehab is needed.
This experience is usually described with some version of: “I had heart surgery and the most confusing part was…a definition.”

The practical lesson people share afterward is simple: ask directly, “Am I admitted as an inpatient?” and request clarification in writing if possible.
It’s not being difficultit’s being financially functional.

Experience #4: The “recovery has a billing timeline” realization

Many people expect one big hospital bill. Instead, they get a sequence: hospital claim, surgeon claim, anesthesia claim, imaging, lab work, possibly a separate
cardiology group, then cardiac rehab visits weeks later. Emotionally, it can feel like the bills are “still arriving” even after you’re back home walking laps
around the living room like it’s an Olympic event.

The best coping strategy people report is building a simple folder system (paper or digital): one folder for Explanation of Benefits (EOBs), one for provider
bills, and a sticky-note list of what’s been paid, appealed, or questioned. It’s not glamorous, but it keeps you from paying the same bill twiceor ignoring
a bill you actually need to challenge.

If there’s one theme across these experiences, it’s this: Medicare usually covers the medical “big rocks” of open-heart surgery, but your personal outcome
financially and emotionallyimproves when you clarify status, confirm networks/assignment, and plan for recovery services like rehab.