The National Eye Institute reports the risk of suffering from cataracts increases significantly after the age of 40. For this reason, the number of cataract cases in the United States has increased 20% from 2000 to 2010.
What’s astounding is that by 2050, it is estimated that there will be double the cases – about 50 million!
The chance of you or your loved ones having cataract surgery is high, so understanding what Medicare covers is important because it is a pricey procedure.
Medicare Coverage for Cataract Surgery
One of the most common questions asked about the procedure is, “Does Medicare cover cataract surgery?” While Medicare doesn’t cover vision care in the general sense, it does cover it when it is medically necessary, such as in the case of cataract surgery.
Original Medicare Coverage for Cataract Surgery
Cataract surgery is covered by Medicare Part B. This part of Original Medicare is for outpatient services.
Original Medicare covers:
- Cataract Removal
- Lens Implants
- Pair of Eyeglasses or Contact Lenses
Intraocular lens implants (small clear disks for better focus) are covered, but more advanced implants are not part of the coverage.
If the ophthalmologist recommends more advanced implants, you may need to pay the difference outside of what Medicare covers. Before receiving the surgery, speak to your healthcare provider about the costs associated with the procedure and what Original Medicare will cover.
Several factors are considered when Medicare reviews the claim for cataract surgery.
- The Medicare claims representative will look at the Medicare plan. While cataract surgery is covered under Part B, not everyone has it, and it may be covered by Medicare Part A or Medicare Part C, depending on the situation (inpatient or a hospital stay).
- The type of cataract surgery that is being performed – standard surgeries are covered while more advanced ones such as laser-assisted are not always covered.
- Pre-existing conditions are a consideration as well.
- Where the surgery takes place, such as a surgery center, clinic, or hospital matters.
Despite the coverage from Medicare or medical insurance, many patients can still be responsible for out-of-pocket costs in the way of physician/surgeon fees, copayments, and deductibles.
There may also be out-of-pocket expenses if you decide on premium implants instead of the standard mono-focal ones.
Medicare coverage for a pair of prescription eyeglasses or contact lenses depends on where you get them. Not all suppliers will accept Medicare for eyeglasses and contact lenses, which means you may have to pay more for them.
Under Original Medicare, you will be expected to pay a Part B deductible of 20% of the Medicare-approved amount for the pair of glasses or contact lenses.
Medicare Supplement Plans (Medigap)
For the amount Medicare doesn’t cover for cataract surgery, Medigap (coinsurance) may help. Most often, it will pay for the deductibles and copays for Medicare Part A and B.
What Medicare Advantage Plans Cover
Medicare Advantage plans also cover cataract surgery like Original Medicare but it has different costs and conditions, depending on the insurance provider. If you have a Medicare Advantage Plan or are thinking of getting it, it’s important to speak to someone about the costs and conditions of each insurance company before deciding on a private insurance policy.
Cost of Cataract Surgery
The cost of cataract surgery depends on a few factors:
- Type of cataract surgery (Phacoemulsification or Extracapsular)
- The expertise of the surgeon
- Type of IOL implanted
For standard cataract surgery, patients can expect to pay $3,000 to $5,000 per eye out-of-pocket. This gives you a grand total range of $6,000 to $10,000 for both eyes. Fortunately, this is the cataract surgery Medicare covers.
Advanced types of cataract surgery, such as laser-assisted cataract surgery, can cost $4,000 to $6,000 per eye. Grand total for both eyes ranges in cost from $8,000 to $12,000 and this is not covered by Medicare.
Medicare Part B covers the surgery and associated doctor and surgery center fees. They will only pay for Medicare-approved amounts, though. So, they will not pay all of it.
Patients pay their deductible and then 20% Medicare Part B copay. To put it in perspective, without Medicare someone may pay $3,500 for the procedure, but with it, they may pay 20% of that – $700.
Additional costs may be incurred for eye exams and prescription drugs.
Drugs for Cataract Surgery Covered by Medicare
Medicare Part D provides prescription drug coverage for outpatient prescription drugs. It is offered by private health insurance companies or as a stand-alone plan for those who have Original Medicare. It can also be part of a Medicare Advantage Plan.
Medicare Part D has a list of drugs it covers – formulary. For drugs not listed in the formulary, it is possible to request an exception or file an appeal if you paid out of pocket.
Medication prescribed before cataract surgery includes Ofloxacin or Zymar. They are antibiotic eye drops that prevent infection. Cyclopentolate dilating drops help prepare the eye for surgery.
Following surgery, Prednisolone Acetate 1% is prescribed to reduce inflammation.
Cataract surgery drugs are covered by Medicare Part D and may be covered by Medicare Advantage Plans as well. Again, check with your insurance plan representative to learn more about coverage and possible co-pays with your Medicare Advantage Plan.
Overview of Medicare Coverage for Cataract Surgery
Medicare does cover cataract surgery, but not fully. You will need to pay the deductible and 20% of the co-pays. This could lead to an out-of-pocket expense of around $700 depending on the total cost of your standard cataract surgery.
Medigap may be able to help with the out-of-pocket expense, so explore that option if you’re unable to afford the remaining balance from the surgery.
The first step is to speak to your healthcare provider to understand the out-of-pocket expenses, and then seek additional assistance from Medigap or private insurance.
Those who do not have Original Medicare but instead, Medicare Advantage Plan, will need to speak to a representative to learn about the specific costs associated with the surgery, as there are many different plans with varying costs and conditions.