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Medicare Critical Illness Coverage

Table of Contents

Summary: Critical Illnesses, such as heart attacks or strokes, require crucial healthcare intervention that often comes at a high cost. Fortunately, many services and supplies related to critical illnesses are covered by Medicare. For those worried about their out-of-pocket expenses, there are options. Below, we’ll discuss how critical illnesses are handled by Medicare and what options you have for supplemental coverage. Estimated Read Time: 9 min

What is a Critical Illness?

Throughout our lives, we experience a variety of illnesses that range in severity. As we age, it becomes essential to be aware of severe illnesses that can put your life at risk. These conditions are referred to as critical illnesses.

Critical Illnesses are life-threatening conditions that can have a significant impact on your day-to-day life. The National Library of Medicine states that a critical illness is defined by the following attributes: high risk of imminent death, vital organ disfunction, potential reversibility, and requirement for care to avoid death. Critical illnesses include (but are not limited to):

  • Heart attack
  • Stroke
  • Major organ transplant
  • Life-threatening cancer

Making healthy choices such as eating balanced meals and exercising can help reduce the risks of some critical illnesses, however, aging is a contributing risk factor for many critical illnesses that we can’t do much about. Fortunately, if you are diagnosed with a critical illness, you have coverage options available. Below, we’ll discuss how Medicare handles critical illness care and which supplemental options are available.

Coverage for Critical Illnesses from Medicare

Medicare provides coverage for services and supplies deemed medically necessary by your doctor or health care provider, and therefore, covers treatment for critical illnesses. If you have Original Medicare, treatment for critical illnesses such as a heart attack or stroke will be covered by your Medicare Part A and Medicare Part B. If you have a Medicare Advantage plan, your plan will be billed for all covered services and supplies.

When you receive care, you will be responsible for paying deductibles, copayments, and coinsurance out-of-pocket. These amounts will vary depending on whether you have Original Medicare or a Medicare Advantage plan. If you have Original Medicare with a Medicare Supplement plan, you may have little to no out-of-pocket costs (depending on your plan).

Does Medicare Cover Heart Attacks? When you receive treatment in an inpatient setting for a heart attack, your treatment will be covered by Medicare Part A. Medicare will cover open-heart surgeries such as bypass surgery, heart transplant, or valve replacement. After receiving treatment, Medicare Part B will cover cardiac rehabilitation services and any follow-up appointments in an outpatient setting. Your Medicare Part A and Part B deductibles and copayments/coinsurance apply.

What Coverage Does Medicare Provide to Individuals Who Have a Stroke? Medicare will provide coverage for services and supplies deemed medically necessary by your healthcare provider following a stroke. Medicare Part A coverage includes inpatient rehabilitation and care at a skilled nursing facility that is necessary following a stroke. Medicare Part B will help cover the costs of physical therapy and any medically necessary equipment, such as a walker.

Does Medicare Cover Organ Transplants? Organ transplants, including necessary tests, labs, and exams are covered by Medicare. Medicare Part A will cover services for heart, lung, kidney, pancreas, intestine, and liver organ transplants. This includes the procurement of organs, immunosuppressive drugs, and stem cell transplants. Your Medicare Part B will cover doctors’ services related to your organ transplant and immunosuppressive drugs if Medicare paid for your transplant.

If you are administered drugs as part of a surgery or inpatient procedure, those will typically be covered under Medicare Part A. Medications that are prescribed following the diagnosis and treatment of a critical illness will need to be paid out-of-pocket unless you have a Medicare Part D Prescription Drug plan or a Medicare Advantage plan with drug coverage.

Many critical illnesses are also considered severe chronic conditions because they significantly impact your health long after diagnosis. If you are diagnosed with cancer or have had a stroke, you may qualify for a Chronic Condition Special Needs Plan. These plans are a type of Medicare Advantage plan that tailors their coverage to meet the needs of individuals with severe or disabling chronic conditions. Availability of Special Needs Plans vary between carriers and location.

Critical Illness Insurance

If you have a family history of serious medical conditions or illnesses, you may consider getting Critical illness insurance. Critical illness insurance is a supplemental insurance plan that helps with the costs of treatment for a critical illness such as cancer, a heart attack or stroke. These plans are offered by private insurance companies, and you can enroll in a plan regardless of whether you have Original Medicare or a Medicare Advantage plan.

How Does Critical Illness Insurance Work?

Before enrolling in a critical illness insurance plan, you will want to research and compare plans that are available in your area. There are important pieces of information you should review when comparing policies such as:

  • Which illnesses does the policy consider critical illnesses?
  • Is there a waiting period before you can receive your benefits? And if so, how long is it?
  • Does your policy have a reduction schedule?
  • What other requirements are there to receive your benefit?

When you have a critical illness plan, you will receive a lump-sum payout when you are diagnosed with an eligible condition. Some plans may offer additional payouts for subsequent events such as the recurrence of a previously covered illness or the diagnosis of a new illness.

The amount you receive will depend on the maximum lifetime benefit amount you choose when enrolling in your plan. Generally, the higher your maximum lifetime benefit, the higher your monthly premium. Your payout may also vary depending on your illness. For many critical illnesses, your policy will payout 100% of your maximum lifetime benefit when diagnosed. However, your policy may offer smaller payouts, such as 25% of your maximum lifetime benefit, for specific conditions. Here’s an example:

Your critical illness plan has a maximum lifetime benefit of $10,000. It offers 100% lump sum payment if you have a heart attack, so you would receive the full $10,000 once diagnosed with a heart attack. Let’s say your plan offers a 25% lump sum payout for non-invasive cancer. If you were to receive a diagnosis for non-invasive cancer, you would instead receive $2,500.

Lump sum payouts from your critical illness insurance can be used however you need them. This can include paying for your Medicare copayments and deductibles, as well as helping pay for groceries or bills while you’re receiving treatment. Since these funds can be used however you need, they can help reduce the financial burden that comes with being diagnosed with a life-altering illness.

Should You Get Critical Illness Insurance? Considerations to Make

Does it sound like critical illness insurance may be a good option for you? Before signing up for a plan, here are a few considerations you should make:

What coverage do you currently have? Before signing up for a critical illness plan, review your current coverage. Though Medicare Supplement plans and Medicare Advantage plans do provide coverage for treatment, diagnosis, and prevention of critical illnesses, you may still be responsible for out-of-pocket costs like deductibles and copayments. Reviewing your existing benefits can help you determine if a supplemental plan like a critical illness policy is worth getting.

Does a supplemental plan fit into your budget? Monthly premiums for critical illness insurance will depend on the carrier, your maximum benefit amount, and your age. For Medicare beneficiaries who have a fixed income, it is essential to consider whether you can afford to purchase a critical illness policy.

Your age can impact your coverage. For individuals who are eligible for Medicare under the age of 65, this may be less of a concern. However, for those 65 and older, you will want to read policies carefully before getting critical illness insurance. Not only will your age affect your premium, but it may reduce your payout as well. Some policies have reduction schedules, which reduce your maximum benefit payout depending on your age. Other policies may make you ineligible for payment once you hit a certain age.

Is cancer the primary reason you’re considering critical illness insurance? Though life-threatening cancer is covered by most critical illness insurance policies, you may have better options when it comes to cancer coverage. Medicare covers medically necessary services related to cancer treatment and prevention, and cancer insurance can provide benefits similar to a critical illness plan.

How to Enroll in Critical Illness Coverage

If you determine that critical illness insurance is a good option for you, you can begin the enrollment process.

  1. First, you’ll need to find a plan. Take time to compare multiple plans that are available in your zip code to find a plan that meets your budget while covering the critical illnesses that are most relevant to you. Make sure you’re looking at plans that are offered to individuals, as some insurance companies only offer group critical illness insurance plans to employers. If you have a life insurance policy, you may consider contacting your insurance company to see if they offer critical illness insurance as a rider (add-on) to your life insurance plan.
  2. When you find a plan that fits your needs, you can generally do the application process online through the insurance provider’s website.
  3. During the application process, you will need to fill out your personal information as well as answer questions regarding your health. This is known as “medical underwriting” and will be used to determine which coverage you’re eligible for and how much your monthly premium will be. If you’re applying for a plan with a very high coverage amount, a medical exam may be part of the underwriting process.
  4. Once you have enrolled in a critical illness plan, you will need to pay your premium each month to stay enrolled. Like many insurance plans, your plan will automatically renew each year if you continue to pay your premium. However, depending on your plan’s terms, there may be an age limit for guaranteed renewal. For example, you may only be guaranteed renewal until age 70, at which point you may age-out of your coverage and need to find a new plan.

Resources for Individuals with a Critical Illness

Critical illnesses can have a significant impact on your life, whether you’ve just been diagnosed or have already undergone treatment. These illnesses can cause sudden changes in your life and adjusting can be difficult. Fortunately, there are resources available to help you learn more about your condition and connect with support networks that can help you navigate life after diagnosis.

The American Heart Association provides ample information on heart-related conditions such as heart attack, heart failure, and problems with heart valves. Their support network helps connect individuals with heart conditions and caregivers so they can ask questions or share their experiences.

The American Stroke Association is a great resource for not only stroke patients, but also caregivers. They provide informational articles, support options for caregivers, information regarding financial resources, and more.

Individuals who are diagnosed with cancer can find helpful resources at the American Cancer Society. Not only does the American Cancer Society provide patient programs such as free rides to treatment, but they also help cancer survivors connect with one another for support. They have a 24/7 cancer hotline where you can get more information on patient resources and programs.

If you have questions regarding Medicare coverage for critical illnesses, you can speak with a licensed insurance agent at the number above. Our agents can help answer questions related to Medicare coverage, out-of-pocket expenses, and more.


Towards definitions of critical illness and critical care using concept analysis, National Library of Medicine. Accessed January 2023


Is Your Test, Item, or Service Covered? Medicare.org. Accessed January 2024


Critical Illness Plan, HealthInsurance.org. Accessed January 2024


Thomas Liquori

Thomas Liquori

Ashlee Zareczny

Ashlee Zareczny

Compliance Supervisor and Licensed Medicare Agent
Ashlee Zareczny is the Compliance Supervisor for ApplyforMedicare. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.