Does Medicare Cover Cataract Surgery? An Investigative Look

Cataract surgery remains a very sensitive procedure for many but also the one which can cost you a lot if you don’t have a government as supportive and helpful as the one we have in the US as here the state covers this surgery too but under specific conditions.

By the time they reach the age of 80, around half of all adults in the United States have cataracts or have had cataract surgery.

In most cases, Medicare Part B (outpatient insurance) covers 80 percent of the costs of cataract surgery. Following the surgery, you will receive one pair of spectacles.

If cataract surgery necessitates a hospital stay, it will be covered by Medicare Part A, which is hospitalisation insurance. Parts A and B are covered under Medicare Advantage, or Medicare Part C, plans.

The costs of cataract surgery are explained in this article, as well as which charges Medicare will and will not cover.

Cataracts and cataract surgery

Cataracts and cataract surgery are two terms that are often used interchangeably.

When your eye’s clear lens becomes rigid or clouded, a cataract develops. Cataract symptoms include:

• vision that is foggy, fuzzy, or dim
• colors that have faded or yellowed
• double vision makes it difficult to see at night, and you may notice halos surrounding lights.
• alterations in vision caused by sensitivity to intense light and glare

Cataract surgery involves the removal of the clouded lens and the surgical implantation of a replacement lens. An ophthalmologist, or eye surgeon, performs this surgery. Cataract surgery is commonly performed as an outpatient treatment. This implies you won’t need to spend the night in the hospital.

Is cataract surgery covered by Medicare?

The most prevalent cause of cataracts, according to the American Academy of Ophthalmology, is ageing. As a person gets older, normal proteins in the lens begin to break down. This breakdown creates cloudiness in the lens over time, which can cause visual problems.

Research on cataract surgery and Medicare

According to research, around 3.6 million people in the United States receive cataract surgery each year as of 2015.

Because cataract surgery is usually done as an outpatient procedure, it is covered by Medicare Part B. This covers some post-surgery expenses. Medicare usually covers 80% of the overall surgical cost, which includes both the surgery and the facility fees.

Prescription glasses are usually not covered by Medicare. After cataract surgery, one pair of spectacles or contact lenses is the only exception.The following services are included in the plan:

• examinations prior to surgery
• postoperative exams one pair of prescription glasses after surgery excision of the cataract implantation of the lens

People should examine their annual deductible for Medicare Part B because a variety of circumstances might alter the cost.

Inpatient hospital stays are covered under Medicare Part A. After cataract surgery, most people do not need to stay overnight. However, if a hospital stay is required owing to serious problems, Part A will cover the additional costs of lodging.

Traditional Medicare is replaced by Medicare Advantage, or Medicare Part C, plans. As a result, they must give at least equal coverage for all procedures, including cataract surgery.

Medicare Part D is a prescription drug coverage provided to Medicare Part A and B beneficiaries. If a person with a Part D plan needs to take a prescription medicine at home after cataract surgery, their plan will most likely cover a portion of the cost.

Medicare and its supplement plans such as private insurance policies

Medicare supplement plans, commonly known as Medigap plans, are private insurance policies that assist consumers in covering the 20% of expenditures not covered by Medicare. These plans may, for example, cover deductibles, copayments, and other out-of-pocket costs.

A supplement plan can be applied for by anyone who has Medicare Parts A and B. The price varies. A person who has a Medicare Advantage plan is unable to purchase a Medigap policy.

Understanding Medicare Coverage for Cataract Surgery

Medicare typically covers medically necessary cataract surgery, but coverage requirements vary by region. Check your local Medicare carrier’s criteria before proceeding.

Medicare covers the majority of cataract surgery expenses, but 20% remains the patient’s responsibility. Additional costs such as deductibles and eye drops may also not be covered.

The patient’s share of cataract surgery costs depends on the type of procedure required. Medicare reimburses the same amount for both laser and non-laser surgery.

Patients needing laser surgery, often due to astigmatism, must cover the extra expense themselves. This procedure is pricier and involves premium lens implants.

Medicare covers standard monofocal lenses used commonly in cataract surgery. However, more advanced lenses like multifocal and toric may not be covered.

Procedures unique to the implantation of advanced lenses not covered by Medicare are also excluded.

Choosing the right lens depends on the patient’s lifestyle and daily activities. Discuss options and associated costs with your eye doctor before surgery.

Before undergoing surgery, ask key questions to assess potential out-of-pocket expenses.

Verify if the doctor is a Medicare provider and where the surgery will be performed. Determine whether it will be an inpatient or outpatient procedure.

Inquire about the medications likely to be prescribed before and after surgery. Additionally, ask for the procedure’s Medicare code to assess coverage accurately.

How Much Does Medicare Cataract Surgery Cost With No Extra Coverage?

Cataract surgery is usually covered by Medicare with no extra cost to the patient. However, there may be some out-of-pocket costs associated with the surgery, such as for the facility fee or for any post-operative care that is needed. Medicare does not cover the cost of eyeglasses or contact lenses after cataract surgery.

What is the average cost of cataract surgery?

Some researchers discovered rates of over $2,700 for one eye and somewhat more than $5,200 for both eyes.

The cost of cataract surgery, on the other hand, varies by state and individual. It may cost more, for example, depending on the type of treatment and whether the surgery is performed in an outpatient surgical facility or a hospital.

The fees charged by surgeons differ, which can affect the total cost of the treatment. Furthermore, the type of lens implant affects the cost.

For the most realistic image of the final cost, it is best to discuss the whole expenses with the surgeon.

What is the price of private cataract surgery?

What is covered by Medicare and private insurance, and what isn’t

The cost of private cataract surgery is determined by the following factors:

• Your surgeon’s billing strategy
• Coverage under your health insurance
• If you’re uninsured, the type of lenses you utilise
• Your situation is unique.

We’ll go over each one in turn in this article.

Medicare does not cover vision care in general, although it does cover some medically essential services like cataract surgery.

Medicare advantage plans

These procedures are covered under Part B, which covers outpatient services, if you have Original Medicare. Medicare Advantage Plans provide the same benefits as Original Medicare, but at a higher cost and with fewer restrictions. If you have a Medicare Advantage Plan, speak with a representative about how your plan handles cataract surgery.

Medicare specifically covers:

• The cataract is removed.
• Implants for basic lenses
• After the surgery, you will need one pair of prescription eyeglasses or contact lenses.

Cataract surgery with intraocular lens implants, which are little transparent discs that help your eyes concentrate, is covered by Medicare.

Implants and lens

Basic lens implants are covered by Medicare, but more complex implants are not. You may be responsible for part or all of the expense of more advanced lens implants if your specialist prescribes them. Before the procedure, speak with your health care practitioner to determine which expenditures will be your responsibility and which will be covered by Original Medicare or your Medicare Advantage Plan.

Medicare will also fund one pair of glasses or contact lenses after the surgery. This is an exception to the general rule that eyeglasses are not covered by Medicare. If you have Original Medicare, you should acquire your glasses or contact lenses from a supplier who accepts assignments to save money on your purchase.

The glasses or contact lenses will cost you 20% of the Medicare-approved price. Contact a Medicare Advantage Plan representative to find out where you should receive your glasses or contact lenses if you have one.

Following cataract surgery, some Medicare recipients may have difficulty getting Original Medicare or their Medicare Advantage Plan to cover their glasses or contact lenses. You have the right to appeal if your glasses or contact lenses are denied coverage. You can ask for the glasses or contact lenses to be covered, or for reimbursement if you previously paid for your prescription out of pocket.

Moreover, you and your health-care professional can both submit letters to the plan requesting reconsideration. Make it clear that your prescription glasses or contact lenses must be funded because you met the Medicare standards for cataract surgery.

What is the price of cataract surgery?

Cataract surgery is divided into two types. Both operations are covered by Medicare at the same rate. These are a few examples:

• Phacoemulsification: This procedure employs ultrasound to break up the clouded lens before removing it and replacing it with an intraocular lens (IOL).
• Extracapsular: This procedure involves removing the clouded lens in one piece and replacing it with an IOL.

The type of surgery that is best for you will be determined by your eye specialist.

According to the American Academy of Ophthalmology (AAO), the cost of cataract surgery in one eye without insurance in 2014 was over $2,500, which included the surgeon’s charge, outpatient surgery centre fee, anesthesiologist’s fee, implant lens, and three months of postoperative care.

These rates, however, will differ by state and the specifics of a person’s condition and needs.

Eyeglasses and Contacts After Cataract Surgery

It is common to experience some changes in your vision after cataract surgery. These changes are usually temporary and will resolve on their own within a few weeks or months. In some cases, however, you may need to wear glasses or contact lenses to correct your vision.

Your ophthalmologist will be able to advise you on what type of eyewear is best for you, based on the extent of your vision loss. In most cases, you will be able to return to your normal activities, including driving, within a few days or weeks after surgery.

How much does Medicare cover?

The cost of cataract surgery will be determined by the following factors:

• The sort of surgery you require is determined by your Medicare plan.
• how long your procedure will take and where you will have it (clinic or hospital)
• You may also experience difficulties from other medical disorders.

Paying for Cataract Treatment With Extra Medicare Coverage

Cataract surgery is one of the most common procedures performed by Medicare-participating surgeons. According to 2014 data from the Centers for Disease Control and Prevention (CDC), about 1.6 million adults aged 65 and over had cataract surgery in that year alone.While Original Medicare (Part A and Part B) will cover some of the costs associated with cataract surgery, there are certain fees—such as the surgeon’s fee, the facility fee, and the cost of the intraocular lens (IOL)—that are not covered.

This is where extra Medicare coverage, like a Medigap plan or a Medicare Advantage plan , can help cover some of the costs that Medicare doesn’t. What does cataract surgery involve? Cataract surgery involves removing the cloudy lens of the eye and replacing it with a clear artificial lens. The surgery is usually performed on an outpatient basis, which means you won’t have to stay in the hospital overnight.

Medicare cost of cataract surgery

The following is an estimate of the cost of cataract surgery:

• The average total cost in a surgery centre or clinic is $977. Your cost is $195, and Medicare pays $781.
• The average overall expenditure in a hospital (outpatient department) is $1,917. Your expense is $383, and Medicare pays $1,533.
• These costs do not cover physician fees or other treatments that may be required, according to Medicare.gov. They are national averages that may vary depending on where you live.

How much does cataract surgery cost under Medicare?

Basic cataract surgery is covered by Medicare, which includes:

• the cataract lens implantation is removed

After the surgery, you will need one pair of prescription eyeglasses or contact lenses.

A, B, C, and D are the four primary elements of original Medicare. A Medigap, or supplement, plan can also be purchased. Each section addresses a different type of medical expense. Several aspects of your Medicare plan may fund your cataract surgery.

Part A of Medicare

Part A of Medicare covers inpatient and hospital expenses. While cataract surgery is usually performed without the requirement for hospitalisation, if you do need to be admitted to the hospital, this would be covered under Part A.

Part B of Medicare

Part B of Medicare covers outpatient and other medical expenses. Your cataract surgery will be covered under Part B if you have Original Medicare. Part B also includes doctor’s appointments, such as visits to your eye doctor prior to and after cataract surgery.

Part C of Medicare

The Part C (Advantage Plans) of Medicare covers the same services as Parts A and B of Original Medicare. All or portion of your cataract surgery may be covered depending on the Advantage Plan you select.

Part D of Medicare

Certain prescription drugs are covered through Medicare Part D. If you require prescription medication as a result of cataract surgery, Medicare Part D may cover it. You could have to pay out of pocket if your drug isn’t on the approved list.

If your surgery-related medications are considered medical expenditures, Part B may cover them as well. If you only need to take certain eye drops before your surgery, for example, Part B may cover them.

Supplemental plans for Medicare (Medigap)

Medicare supplement plans (Medigap) cover various expenses that are not covered by Original Medicare. Call your healthcare provider if you have Medigap coverage to find out what expenses it covers. Some Medigap plans cover Medicare Parts A and B deductibles and copays.

How can you know how much cataract surgery will cost before you have it done?

You’ll need information from your eye doctor and Medicare to figure out how much you’ll have to spend out of pocket for cataract surgery.

Your doctor may be able to tell you what much of your operation is covered by insurance and how much you’ll have to pay out of pocket.

Your private insurance provider can inform you of your projected out-of-pocket payments if you have acquired a Medicare Advantage or other plan via them.

What other factors might influence the amount you pay?

Your Medicare coverage and the plans you choose will decide the exact amount you will pay out-of-pocket. Other coverage factors that influence your out-of-pocket expenses are:

• your Medicare strategies
• your insurance deductibles
• if you have other health insurance if you have Medicaid if Medicare Part D covers the meds you’ll need if you have other medical problems that make the surgery more complex if you have other medical conditions that make the process more complex
• If you are a veteran, your VA benefits may make cataract surgery more reasonable.

How do I prove my eligibility?

If you’re 65 or older and your doctor has determined that cataract surgery is medically essential, Medicare will normally cover 80% of your costs, including the cost of post-surgical eyeglasses or contacts.

While coverage varies from region to region and between local carriers, cataract surgery is covered as long as your doctor accepts Medicare as payment.

Is there any other cost related to cataract surgery that Medicare will cover?

Though Medicare covers 80% of the cost of cataract surgery with intraocular lens implants, more advanced procedures may need you to fund a larger portion, or perhaps the entire cost.

After your operation, Medicare will cover one pair of glasses, but things like updated frames, additional pairs of contact lenses, and other treatment-related products like eye drops are unlikely to be covered. It’s also crucial to talk to your healthcare provider about what is and isn’t covered under your plan to avoid any unexpected expenditures.

Medicare and routine eye care

Routine eye care services, such as regular eye examinations, are not covered by Medicare. If you have a chronic eye problem like cataracts or glaucoma, Medicare will fund some eye care services. Medicare pays for the following:

Surgical treatments to aid in the repair of eye function caused by chronic eye diseases. For example, Medicare will pay for cataract surgery and the replacement of your eye’s lens with a manufactured intraocular lens.

If you had cataract surgery and had an intraocular lens implanted in your eye, you’ll need eyeglasses or contacts. If you need a basic pair of untinted prescription eyeglasses or contacts, Medicare will fund them. Medicare may pay for customised eyeglasses or contact lenses if they are medically required.

An eye exam is performed to determine whether or not you have any visual difficulties.

Medicare will fund an eye checkup if you are experiencing vision issues that could signal a serious eye condition.

Only the following situations are covered by Medicare for routine eye care:

If you have diabetes, Medicare will pay for an annual eye exam by a state-licensed eye doctor to screen for diabetes-related visual issues.

Medicare pays an annual eye exam by a state-authorized eye doctor if you are at high risk for glaucoma. If you do any of the following, you are considered to be at high risk:

• Do you have diabetes?
• Do you have a history of glaucoma in your family?
• Are you African-American and over 50 years old?
• Are you Hispanic American and above the age of 65?

FAQS

How much does cataract surgery cost in 2022?

Cataract surgery is one of the most common procedures performed by ophthalmologists. In the United States, the average cost of cataract surgery is $3,000 per eye. However, the cost of cataract surgery can vary depending on a number of factors, such as the type of procedure, the experience of the surgeon, and the location of the surgery. In some cases, insurance may cover part or all of the cost of cataract surgery. For those who do not have insurance, there are a number of financing options available to help cover the cost of the procedure.

What vision coverage does Medicare provide?

Medicare provides coverage for some screenings and therapies related to cataract surgery. However, Medicare does not cover the cost of the surgery itself. Patients who are covered by Medicare may be responsible for a portion of the cost of their surgery, depending on their specific plan. There are a number of ways to finance cataract surgery, including private insurance, government assistance programs, and financing through the surgeon’s office. Patients should speak with their surgeon or ophthalmologist to determine which financing option is best for them.

Does Medicare pay for cataract surgery with astigmatism?

Medicare does not cover the cost of cataract surgery with astigmatism. However, there are a number of financing options available to help cover the cost of the procedure. Patients should speak with their surgeon or ophthalmologist to determine which financing option is best for them.

Does Medicare cover eye exams, glasses or contact lenses?

Medicare does not cover the cost of routine eye exams, glasses, or contact lenses. However, Medicare does cover the cost of some screenings and therapies related to cataract surgery. Patients who are covered by Medicare may be responsible for a portion of the cost of their surgery, depending on their specific plan.

Conclusion

Cataracts, a common eye ailment among the elderly, often require surgery, which is typically effective. Medicare covers medically necessary cataract surgery.

Medicare generally covers 80% of cataract surgery costs, leaving patients to consider options for the remaining 20%, like Medicare supplement plans such as Medigap.

For guidance on payment for cataract surgery, it’s best to directly contact your insurance provider.

While Medicare covers a significant portion of cataract surgery expenses, it does not cover all, and Medigap may not make it entirely cost-free.

You may be responsible for deductibles, co-payments, co-insurance, and premium costs associated with cataract surgery. Additionally, more advanced procedures or health complications may lead to additional payments.