When a Medicare-approved healthcare provider confirms that a cardiac pacemaker is medically necessary and appropriate for a person’s treatment, Medicare will cover it.
A person is eligible for Medicare coverage when they are age 65 years or above. Individuals younger than 65 years old may also be eligible if they have certain health conditions.
The part of Medicare that covers pacemakers and their related costs will vary depending on the setting and service type.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The Centers for Medicare and Medicaid Services will cover cardiac pacemakers as a prosthetic device. They must be medically necessary to treat a person’s heart condition.
There are four parts to Medicare that may help with the costs of a pacemaker. The following sections will look at these in more detail.
Part A covers a person for inpatient hospital care. The procedure to fit a pacemaker often takes place in a hospital, meaning that Part A would cover eligible costs.
Medicare Advantage plans would also cover eligible expenses, as they must provide the same Part A benefits.
Under Part A, an individual must pay some out-of-pocket expenses, such as the benefit period deductible, which is $1,484 in 2021. The day a person is admitted to a hospital is when the benefit period begins. This period will end once they have been home from the hospital for 60 consecutive days.
Medicare Part B covers outpatient medical care and can help cover the cost of doctor visits, such as if adjustments to the pacemaker take place on an outpatient basis.
A person will usually pay a coinsurance of 20% of eligible outpatient costs in addition to a monthly premium. The standard 2021 premium is $148.50.
The amount a person pays for their Part B premium will depend on their income reported to the Internal Revenue Service 2 years earlier. This means that an individual’s 2021 premium will vary depending on their reported income from 2019.
Part C (Medicare Advantage)
Medicare Advantage plans combine the benefits of original Medicare parts A and B, so coverage for pacemakers follows the same benefit rules.
Private insurance companies administer Medicare Advantage plans, and these often provide additional coverage, such as dental or optical care.
Medicare Advantage premiums vary depending on the insurance company, a person’s plan, and their location. Out-of-pocket expenses may also vary, and plans may charge more if a person uses a provider outside of their network.
Private insurance companies also administer Medicare Part D plans, which are prescription drug plans.
Part D plans will usually help cover the cost of the prescribed medications associated with pacemakers.
As with Medicare Advantage plans, out-of-pocket costs can vary based on plan provider, where the person lives, and their plan type.
Pacemakers use a battery and a small computer to monitor and control the heartbeat. New pacemakers can also monitor blood pressure and breathing.
The device records all electrical activity from the heart and allows doctors to access these recordings. A doctor can then adjust the settings to a person’s medical needs.
About the heart
Four areas make up the heart: two on the top and two on the bottom.
Blood flows in and out of each area every time the heart beats, pushing blood around the body. The blood delivers oxygen and nutrition to a person’s muscles and organs.
The heart beats around 100,000 times each day, moving approximately 2,000 gallons of blood. Over an average of 70 years, the heart beats more than 2.5 billion times.
A person’s health can largely depend on the regularity of their heartbeat. Having an irregular heart rhythm, or an arrhythmia, increases the risk of a stroke or heart attack due to a lower amount of blood reaching the body and brain. When this happens, a person may experience tiredness, shortness of breath, or feeling faint.
Doctors can recommend pacemakers to treat arrhythmias.
A doctor will evaluate a person’s need for a pacemaker depending on their health condition. The type of heart condition a person has will help the doctor determine the
A person may need a pacemaker to help treat:
- damage after a heart attack
- electrical problems that affect heart rate
- heart failure
- an enlarged heart
There are three main types of pacemaker:
- Single chamber pacemakers: These have one lead that attaches to the top or bottom of the heart.
- Dual chamber pacemakers: These have two leads that attach to the top and bottom of the heart.
- Biventricular pacemakers: Also known as cardiac resynchronization therapy, these special pacemakers have one lead at the top of the heart and two at the bottom, which helps adjust the heart’s rhythm.
For people with limited incomes and resources, several programs can help them pay medical expenses.
- Medicaid: This is a joint federal and state program that helps with medical costs. A person can check their eligibility on the Medicaid website.
- Medicare savings programs: These can help pay out-of-pocket expenses, such as deductibles, coinsurance, and copayments.
- Extra Help: This helps a person cover the costs of their prescription drugs.
- Supplemental Security Income: This is a monthly benefit that the Social Security Administration may pay. It is not the same as retirement benefits.
Medicare will pay for a pacemaker when it is medically necessary and prescribed by a Medicare-approved healthcare provider.
Part A helps cover the costs of inpatient care needed for pacemaker surgery. Part B helps cover the costs of doctor visits to monitor and adjust the pacemaker.
Medicare Part D helps cover the prescribed drugs that a person may need for their heart health.
If a person has a limited income, programs such as Medicaid can help with their medical expenses.