If you have heart disease, or are at risk of developing heart disease, you may want to use a cardiac rehabilitation (CR) program. These medically supervised programs aim to improve the health and well-being of people with heart problems. They provide a range of services in their efforts, from the physical to the psychological, and involve little risk. You could even use a more rigorous intensive cardiac rehabilitation (ICR) program, which offers the same services as a cardiac rehabilitation program with the added assurance that they reduce the impact of cardiovascular disease in their patients. Both CR and ICR programs can improve your overall quality of life, assist with recovery after heart surgery, and prevent future heart problems. Medicare Part B will pay for CR and ICR services in an outpatient setting, under certain circumstances.
To have Medicare cover a CR or ICR program, you must first demonstrate that these programs are medically necessary. Medicare will consider this to be the case if you are referred by your doctor and if you’ve experienced at least one of the following:
- You’ve had a heart attack within the past year.
- You’ve had heart valve surgery, either repairing or replacing one of your heart valves.
- You’ve had a heart transplant or heart-lung transplant.
- You’ve had heart bypass surgery (link).
- You’ve had an angioplasty or coronary stenting to repair your heart’s arteries or remove plaque blockages.
- You have stable angina pectoris, where you feel persistent chest pain because your heart is not getting enough blood/oxygen.
- You have stable, chronic heart failure.
As of February 9, 2018, expanded coverage to beneficiaries who met the following qualifications:
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less despite being on optimal heart
failure therapy for at least 6 weeks
Basically, only heart surgery or severe symptoms of coronary artery disease will qualify you for coverage. Keep in mind that you can benefit from CR/ICR programs even in cases when Medicare doesn’t cover them. If you are overweight, sedentary, smoke, have diabetes, high blood pressure, or high cholesterol, these programs can help prevent you from developing serious heart disease.
Specific Requirements for CR/ICR Programs
Medicare also has specific requirements for the CR/ICR programs. All CR/ICR programs, to get Medicare coverage for their services, must have the following components available:
- Physician prescribed exercise, including aerobic and strengthening exercises. This exercise prescription must be offered each day CR/ICR services are given.
- An individualized treatment plan. This needs to include your diagnosis, treatment goals, as well as the type, amount, and frequency of your treatment. It needs to be signed by a physician every 30 days or Medicare will terminate coverage.
- Education, counseling, and behavior modification (like diet plans) to improve heart health.
- A psychosocial assessment to determine how your psychological functioning relates to your heart rehabilitation.
- An outcomes assessment measured by the physician at the beginning and end of the program. It should objectively measure the effectiveness of the program’s efforts to progress the patient towards improved heart health.
- For ICR programs only, the program must have published, peer reviewed research showing their program reduces the effects of heart disease.
If your CR/ICR program has all of these components and accepts payment from Medicare, you will be covered. However, this coverage only applies for a limited amount of time. CR program sessions can be no longer than one hour, twice per day. You cannot have more than 36 total sessions or be treated for more than 36 weeks without having to ask for an extension from Medicare. If you’re using ICR, you are limited to 72 one-hour sessions. These sessions cannot go on for longer than 18 weeks and there can be no more than six per day.