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.
- Cataracts are when a person’s vision begins to deteriorate and become cloudy.
- Cataract surgery is when a surgeon replaces the clouded lens of a person’s eye with an intraocular lens to restore a person’s clouded vision.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. will cover cataract surgery for certain intraocular lenses.
- Medigap can provide help with the out-of-pocket costs for cataract surgery after Medicare Part B has covered its share.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover cataract surgeries and other eye services, but the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. will have to use providers within the plan.
- Cataract surgery can cost between $3,000 to $5,000 per eye, for which Medicare Part B provides 80 percent coverage.
- Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... will cover post-surgical medications such as eye drops.
What Are Cataracts?
Cataracts are when the lens of the eye begins to cloud, blocking light from entering your eye and making your vision foggy and distorted. This is due to the proteins and fibers in the lens breaking down and clumping up over time. Cataracts can develop in one or both eyes, causing symptoms such as:
- Clouding, blurred or dim vision
- Increasing difficulty with vision at night
- Sensitivity to light and glare
- Need for brighter light for reading and other activities
- Seeing “halos” around lights
- Frequent changes in eyeglass or contact lens prescription
- Fading or yellowing of colors
- Double vision in a single eye
Cataracts cannot be prevented once it starts. Routine eye exams will help an eye doctor catch signs of cataracts early and begin early treatments. Prescription eyeglasses will help counter the effects of cataracts for a short while, but your eyes may reach a point where you need cataract surgery to see clearly.1mayoclinic.org, “Cataracts“, Accessed November 18, 2021
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 necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice., such as in the case of cataract surgery.2Medicare.gov, “Eyeglasses & contact lenses“, Accessed November 18, 2021
Original Medicare Coverage for Cataract Surgery
Cataract surgery is covered by Medicare Part B. This part of Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. is for outpatient services. Original Medicare covers:2Medicare.gov, “Eyeglasses & contact lenses“, Accessed November 18, 2021
- Cataract Removal
- Lens Implants
- Pair of Eyeglasses or Contact Lenses
Several factors are considered when Medicare reviews the claimA request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered. 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 AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. or Medicare Part CMedicare Part C is Medicare's private health plan option. Also known as Medicare Advantage, Medicare Part C plans are a type of Medicare health plan offered by companies that contract with Medicare to provide all..., 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 conditionsA pre-existing condition is any health problem that occurred before enrolling in a health plan. The Affordable Care Act law made it illegal for health plans to or charge more due to a pre-existing condition.... 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, copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., and deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.. There may also be out-of-pocket expenses if you decide on advanced implants instead of the standard mono-focal ones.
Intraocular Lens Implants
Monofocal intraocular lens implants (small clear disks for better focus) are covered, but more advanced implants are not part of the coverage. This is why Medicare also covers a pair of glasses or contact lenses to help your nearsighted vision after the surgery.2Medicare.gov, “Eyeglasses & contact lenses“, Accessed November 18, 2021
If your ophthalmologist recommends more advanced implants, such as multifocal lenses or toric lenses, 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.3eyeconsultantsofpa.com, “Does Medicare Cover Cataract Surgery“, Accessed November 18, 2021
Eyeglasses After Cataract Surgery
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.2Medicare.gov, “Eyeglasses & contact lenses“, Accessed November 18, 2021
Under Original Medicare, you will be expected to pay a Part B deductible of 20% of the Medicare-approved amountA Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges. What Does Medicare-Approved Amount Mean? A Medicare-approved amount is... for the pair of glasses or contact lenses.
Medicare Supplement Plans (Medigap)
For the amount Medicare doesn’t cover for cataract surgery (coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. and deductibles), a Medigap policy may help. Medicare supplement insuranceMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage., as it is also known, helps cover many of the out-of-pocket costs with Medicare Part A and B.7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 17, 2021
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.4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 17, 2021
Cost of Cataract Surgery
The cost of cataract surgery depends on a few factors:4ucfhealth.com, “How Much Does Cataract Surgery Cost?“, Accessed November 18, 2021
- Type of cataract surgery (Phacoemulsification or Extracapsular)
- The expertise of the surgeon
- Type of intraocular lens (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.4ucfhealth.com, “How Much Does Cataract Surgery Cost?“, Accessed November 18, 2021
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.4ucfhealth.com, “How Much Does Cataract Surgery Cost?“, Accessed November 18, 2021
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 for 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.5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 18, 2021
Medicare Part D has a list of drugs it covers, also known as a formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered.. For drugs not listed in the formulary, it is possible to request an exception or file an appeal if you paid out of pocket.5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 18, 2021
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% may be prescribed to reduce inflammation.
Cataract surgery drugs are covered by Medicare Part D and Medicare Advantage plans that include Part D as an additional benefit. Check with your plan 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 expenseOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments., 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.
- 1mayoclinic.org, “Cataracts“, Accessed November 18, 2021
- 2Medicare.gov, “Eyeglasses & contact lenses“, Accessed November 18, 2021
- 3eyeconsultantsofpa.com, “Does Medicare Cover Cataract Surgery“, Accessed November 18, 2021
- 7Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 17, 2021
- 4ucfhealth.com, “How Much Does Cataract Surgery Cost?“, Accessed November 18, 2021
- 5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 18, 2021