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. In fact, more than half of people over the age of 80 have been diagnosed with a cataract. Since most people over the age of 65 are enrolled in Medicare coverage, you might be wondering, “Is cataract surgery covered by Medicare?” If so, what are the details of the coverage? Keep reading as we tell you everything that you need to know about Medicare coverage of cataract surgery so that you will know 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 your eye’s lens becomes foggy or cloudy. When the lens is no longer clear, your vision starts to become cloudy as well. Cataract surgery involves removing your eye’s lens and replacing it 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 you will be responsible for the payment of any necessary copays and coinsurance amounts.
In addition to the surgery itself, your Medicare Part B benefits also cover most of the services related to the surgery. You might already know that Original Medicare does not cover routine eye exams. However, it does cover pre-operative eye exams that are 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.
Medicare Coverage Of Non-Surgical Cataract Treatment
There are many non-surgical treatment options available for cataracts today. These options range 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 will still need to pay your deductible and coinsurance amounts when surgery is required. This is basic Medicare for dummies information, so you should already be aware of this fact. If you can correct your vision with a pair of 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 to get your vision corrected.
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 together into a single health insurance plan. These plans are managed and administered by private insurance companies, and many of these plans 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 provide additional benefits, like vision coverage, dental coverage, gym memberships, and other benefits.
Since Medicare Part B covers cataract surgery, your Medicare Advantage plan must also provide coverage for the surgery. Most of these healthcare plans provide benefits well beyond just cataract surgery. Many of the plans also include vision coverage as well as 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 amounts. You should obtain your plan details from your insurance provider to determine the specifics of your coverage.
Average Cost Of Cataract Surgery
So, how much does cataract surgery cost with Medicare? The cost of cataract surgery can vary widely depending on a few different factors. The things that can affect the cost of the surgery 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 greatly increase for laser surgery or if you require a specialized lens implant.
When it comes to 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, it will cost you just 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. In fact, many Medigap plans will help cover your additional out-of-pocket costs associated with premium cataract surgery. Remember that Medicare supplement plans are managed by private insurance companies, 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 at Medicare.gov. However, most of them provide coverage for your Part B copays and coinsurance amounts. This means that they could cover a large portion of your out-of-pocket expense associated with cataract surgery.
Remember that if your healthcare provider accepts Medicare, then they must also accept your Medigap plan. You can always check with the surgery center that you plan to use prior to scheduling your appointments to confirm that they accept Medicare. Also, keep in mind that if you are eligible for Medicare, you can choose to enroll in either a Medicare Advantage plan or a Medigap plan – but not both! You could also stick with Original Medicare and not enroll in any additional coverage.
The Bottom Line
Medicare Part B covers basic cataract surgery since it is generally performed on an outpatient basis. 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 plan or Medigap plan will usually help lower your out-of-pocket costs associated with cataract surgery.
Frequently Asked Questions
What percentage does Medicare pay for cataract surgery?
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 the 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 are no longer allowed to cover your Part B deductible. Most surgical centers can check your coverage prior to the surgery and provide an estimate of your costs before any services are performed.
Does Medicare cover cataract surgery for people with disabilities?
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 your age or a 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.
Does Medicaid cover cataract surgery?
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.