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.

Exclusions from coverage

Although cataract surgery that is deemed medically necessary by a doctor is normally covered by Medicare, the qualifications for coverage differ by region. A person should examine the requirements of their local Medicare carrier before receiving the surgery.

The remaining 20% of the expense of cataract surgery is not covered by Medicare. Certain additional expenditures, such as deductibles and prescriptions like eye drops, may be excluded as well.

An individual’s part of the cost of cataract surgery is determined by the type of procedure required.

Whether a surgeon performs cataract surgery with or without a laser, Medicare pays the same amount. Laser surgery, on the other hand, is more expensive and is reserved for patients with astigmatism who require a premium lens implant.

The individual will be asked to pay the difference between the covered amount and the additional costs of laser surgery at the surgical centre.During cataract surgery, a surgeon places an intraocular lens into the eye (IOL). However, not all IOLs are covered by Medicare. It does, however, cover monofocal lenses, which are commonly used by surgeons.

Other lenses, like multifocal and toric lenses, are available, however they may not be covered by Medicare. It also doesn’t cover procedures unique to the implantation of these more advanced lenses that a surgeon wouldn’t execute for a standard monofocal lens.

The optimal type of lens for a person having cataract surgery is determined by their lifestyle and daily activities.

They should talk to their eye doctor about it and be aware of the additional costs involved with more modern lenses.

Before having surgery, a person should ask the following questions to evaluate probable out-of-pocket costs:

  • Is the doctor a Medicare provider?
  • Is the surgery going to be performed in a hospital or a surgical centre?
  • Will the surgery be performed as an inpatient or an outpatient procedure?
  • Before and after surgery, what medications is the doctor likely to prescribe?

It’s also a good idea to inquire about the procedure’s Medicare code, as this will aid in determining coverage more precisely through the online tool.

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:

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.

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.

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.

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

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?

Conclusion

Cataracts are among the most frequent eye diseases that affect the elderly. The majority of the time, surgery to correct them is effective. As long as the doctor agrees that cataract surgery is medically essential, Medicare will cover it.

The price of cataract surgery varies. Surgical expenditures are frequently covered by Medicare to the tune of 80%. People may choose to fund the remaining 20% of the cost through Medicare supplement plans such as Medigap.

It is preferable to contact one’s insurance provider directly for advice on how to pay for cataract surgery.

Cataract surgery is a popular operation for which Medicare pays. Medicare, on the other hand, does not cover everything, and Medigap may not make it totally free.

Deductibles, co-payments, co-insurance, and premium costs may be required. If you require more advanced cataract surgery or experience health issues, you may be responsible for additional payments.

Tony Bennett

Tony Bennett

Tony Benett makes his living in the insurance industry by teaching and consulting. He is also recognized by the legal profession as an expert on insurance coverages. His insurance experience includes having worked at the company level, owned an independent general agency and having worked for an insurance association. He has received various certificates over the past few years and helps his clients and readers by giving them a realistic outlook on what they can expect to achieve within their set targets. At Insurance Noon, he is known for his in-depth analysis and attention to details with accuracy. He has been published as one of the most referred agents by his peers in the insurance community. Tony loves the outdoors and most sport events. His passion other than providing excellent advice is playing golf.