Cataracts are much more common than you might think. Over 24 million Americans over the age of 40 are affected by cataracts.
The older you get, the more likely you will suffer from cataracts and need cataract surgery. More than half of people over the age of 80 have been diagnosed with a cataract.
Since most people over 65 are enrolled in Medicare coverage, you might wonder, “Does Medicare cover cataract surgery?” If so, what are the details of the coverage?
Keep reading as we tell you everything you need to know about Medicare coverage of cataract surgery so you will understand how it might affect you should the need for surgery arise.
Does Medicare Cover Cataract Surgery?
Yes, Original Medicare covers cataract surgery and many related exams and services. Cataracts occur when the lens of an eye becomes foggy or cloudy. When the lens is no longer clear, vision starts to become cloudy as well.
Cataract surgery involves removing and replacing your eye’s lens with an artificial lens.
- These surgeries are typically performed as outpatient procedures, so they are covered under Medicare Part B.
- While the surgery is covered, you will be required to meet your Part B deductible and be responsible for paying any necessary copays and coinsurance amounts.
- Your Medicare Part B benefits cover most of the services related to the surgery in addition to the surgery itself.
You might already know that Original Medicare does not cover routine eye exams. However, it covers pre-operative eye exams required before your surgery. It also covers the anesthesia necessary for the surgery, removal of the cataract, a basic artificial intraocular lens implant (IOL implant), post-op exams, and one pair of prescription glasses after the surgery.
While a hospital stay after cataract surgery is unlikely, your Medicare Part A benefits will cover the hospital stay should one be required.
KEY TAKEAWAYS
- Original Medicare covers cataract surgery; however, you must cover any copay or coinsurance amounts.
- Non-surgical cataract options are available; however, they are considered routine vision care and are not covered by Medicare.
- Medicare Part B covers basic cataract surgery at 80% of the Medicare approved amount after deductible.
Medicare Coverage Of Non-Surgical Cataract Treatment
Today, many non-surgical treatment options for cataracts are available, ranging from special eyeglasses to contact lenses. We have already mentioned that Original Medicare does not cover routine vision care.
Unfortunately, these non-surgical treatment options are not covered by Medicare. These options are considered normal vision correction, and Original Medicare does not cover them. You will be required to pay out-of-pocket for these options unless you have a Medicare Advantage plan that provides coverage.
Remember that even with Part B benefits, you must still pay your deductible and coinsurance when surgery is required. This information and more are available in our Medicare for Dummies article.
If you can correct your vision with prescription eyeglasses, your total cost might still be lower with the non-surgical option. Plus, you would not have to go through the process of surgery.
You should discuss your treatment options with your ophthalmologist to determine the best course of action for correcting your vision.
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Cataract Coverage With Medicare Advantage Plans
A Medicare Advantage plan, or Medicare Part C, is an insurance plan that combines all your Original Medicare coverage into a single health insurance plan. Private insurance companies manage and administer these plans, and many provide additional benefits beyond Original Medicare coverage.
- The plans must provide at least the same minimum level of coverage as Original Medicare. However, many plans offer additional benefits, such as vision, dental, gym memberships, and more.
Since Medicare Part B covers cataract surgery, your Medicare Advantage plan must also provide coverage for the surgery. Most of these healthcare plans offer benefits well beyond just cataract surgery.
- Many of the plans also include vision and prescription drug coverage. These additional benefits might help cover your out-of-pocket costs related to non-surgical treatment options.
Your Advantage plan might cover routine visits to your eye doctor, corrective lenses, a set of contact lenses, eye drops, and other things not covered by Medicare.
You will likely still incur additional costs, such as copays or coinsurance. To determine the specifics of your coverage, you should obtain your plan details from your insurance provider.
TIP
In most instances, Medigap will help cover the costs of copays and coinsurance for cataract surgery. It may help offset the cost of laser cataract surgery that Medicare doesn’t cover.
Average Cost Of Cataract Surgery
So, how much does cataract surgery cost with Medicare? The cost can vary widely depending on several factors. These include the physician performing the surgery, the type of lens implant required, and the technology used for the surgery.
- On average, basic cataract surgery costs about $5,000 per eye. Laser cataract surgery with an astigmatism lens implant can cost nearly $15,000.
- Medicare does not typically cover additional costs beyond what is required for basic surgery. So this means that your out-of-pocket cost might significantly increase for laser surgery or if you need a specialized lens implant.
Regarding basic surgery, Medicare Part B covers the service at 80% of the Medicare-approved amount once you have met your Part B deductible.
- Assuming that you have not already met your deductible at the time of the surgery, you will need to pay over $1,000 for your portion of the fees.
Although Medicare covers pre-op exams, post-op exams, and one pair of eyeglasses after the surgery, you will likely need to pay a coinsurance amount for those services as well.
You should also remember that these charges are for surgery on only one eye. Many people need cataract surgery in both eyes, although the surgeries are typically performed on one eye at a time. If you need surgery in both eyes, you can basically double the costs mentioned here.
Cataracts & Medicare Supplemental Insurance
Will a Medicare supplement plan or Medigap plan help pay for the costs of cataract surgery? Most of the time, the answer is yes. Many Medigap plans will help cover extra out-of-pocket expenses associated with premium cataract surgery.
Remember that private insurance companies manage Medicare supplement plans, although these plans are standardized across most states. The specifics of your coverage depend on which plan you have purchased. You can compare Medigap plans online.
However, most provide coverage for your Part B copays and coinsurance amounts. This means they could cover many out-of-pocket expenses associated with cataract surgery.
Remember that if your healthcare provider accepts Medicare, they must also take your Medigap plan. You can always check with the surgery center you plan to use before scheduling your appointments to confirm that they accept Medicare.
Also, remember that if you are eligible for Medicare, you can enroll in either a Medicare Advantage or Medigap plan – but not both! You could also stick with Original Medicare and not enroll in additional coverage.
The Bottom Line
Medicare Part B covers basic cataract surgery since it is generally performed outpatient. If any inpatient care is required, it would be covered under your Medicare Part A benefits.
If you have a Medicare Advantage plan, you will receive at least the same level of coverage. Most Advantage plans provide additional coverage that helps cover routine eye exams and other items.
A Part D drug plan can also help cover prescription drugs, like eye drops, that might be needed as part of your recovery. Enrollment in an Advantage or Medigap plan will usually help lower your out-of-pocket costs associated with cataract surgery.
Frequently Asked Questions
Cataract surgery is covered under your Medicare Part B benefits. This coverage provides for payment of 80% of the Medicare-approved amount once you have met your annual deductible.
This means that you would be responsible for paying 20% of the fee not covered by Medicare. If you are enrolled in a Medigap plan that covers your Part B coinsurance amount, your Medigap coverage can help pay for that amount.
However, Medigap plans can no longer cover your Part B deductible. Most surgical centers can check your coverage before the surgery and provide an estimate of your costs before any services are performed.
Yes, Medicare covers cataract surgery for people with disabilities as long as they are enrolled in Medicare coverage.
Medicare coverage is the same regardless of whether you are enrolled due to age or disability. Since cataracts generally begin to affect people as they age, most younger people do not have a need for cataract surgery.
However, Medicare will still cover your cataract surgery even if you have a disability.
Whether or not Medicaid will cover cataract surgery depends on the state in which you live. Medicare is managed at the state level, so the benefits vary from state to state.
Vision coverage is required through Medicaid for those under age 21; however, it is not guaranteed to adults. Some states cover basic cataract surgery through Medicaid, while other states do not. Since cataracts do not typically affect those under 21, many Medicaid recipients might find themselves without coverage for cataract surgery.
If you find yourself in this situation, you should talk to your eye doctor about the least expensive treatment options. You might find that a non-surgical option works well enough to avoid the surgery.
You can find a Social Security Administration office near you by using our SSA office locator and searching for your closest location.
