If you're over 65, you probably know at least one person who has had cataract surgery, if you haven't had it yourself. And by the time you're 80, one in two of you will either have had cataract surgery or will be dealing with cataracts, according to the National Eye Institute.
Johns Hopkins Medicine says that cataract surgery is one of the safest, most effective, and most common surgeries. In this surgery, the cataract — a clouded area in the eye's natural eye lens — is removed and replaced with a new artificial lens.
Considering how prevalent cataract surgery is, and how your chances of needing it increases with age, you may ask, "Does Medicare cover cataract surgery and implants?"
Which Medicare Plans Cover Cataract Surgery?
When it comes to Medicare and cataract surgery, according to the U.S. Centers for Medicare & Medicaid Services, this is the official definition of what Medicare covers:
"Medicare benefits include a conventional intraocular lens (IOL) following cataract surgery, facility supplies, and physician services to implant the conventional IOL and one pair of glasses or contact lenses as a prosthetic device post-operative."
What type of cataract surgery does Medicare cover? Standard types only, as advanced implants and technologies are generally not covered.
If you're wondering which Medicare part covers cataract surgery, here's how Medicare's various parts cover services:
- Part A is inpatient hospital insurance
- Part B is outpatient and medical insurance
- Part C combines Part A and Part B as Medicare Advantage
- Part D is optional prescription drug coverage
- Medigap is optional supplemental insurance that helps pay Part A and Part B balances
Under Original Medicare: When it comes to paying for medically necessary cataract surgery under Original Medicare — made up of Part A and Part B — Part A will only be called upon in rare instances where hospitalization is required. Most of the coverage will come from Part B since this is typically an outpatient procedure. After the Part B deductible is met, it should cover presurgical appointments, anesthesia, surgery, prescription lenses, and follow-up care.
Part B only pays 80% of Medicare-approved expenses, so if you’d like assistance with the remaining 20% balance, you may want to consider getting a separate Supplement Insurance (Medigap) Plan. Medigap will approve anything Medicare approves, so support is never in question.
Lastly, if you have added a Part D prescription plan to your Original Medicare, your plan should cover the agreed share of any medications required by the surgery.
Under Medicare Advantage: On the other hand, you may be one of the many people who have replaced Original Medicare with Medicare Advantage (Part C). This private alternative must provide Part A and Part B coverage. As such, your plan provider is required to cover the medical costs of cataract surgery. However, you should check directly with your provider about the costs involved, since benefits can vary from plan to plan.
You should also choose doctors and facilities that are within your specific plan's network. Most Medicare Advantage plans also cover prescriptions, so your necessary medications are most likely covered as well.
Medicare Part A & Cataract Surgery
Part A — which covers inpatient hospital services — does not pay for any part of cataract surgery unless your procedure requires being hospitalized, which is very rare. In that case, you would be subject to the deductibles and copayments required by a standard hospitalization.
Medicare Part B & Cataract Surgery
Although Medicare Part B covers many medical services, it does not pay for services related to standard vision care, such as routine eye exams. However, if your doctor says it's medically necessary to remove and replace a lens affecting your vision, you might ask, "Will Medicare pay for cataract removal?"
If you have Original Medicare, the Part B portion will cover the entire outpatient surgery procedure once you have met the annual deductible ($226 in 2023). After that, Part B will pay 80% of the costs Medicare approves for presurgical appointments, surgery, anesthesia, prescription lenses, and follow-up care. The remaining 20% is your responsibility unless you have a Medicare Supplement (Medigap) Plan.
Medicare Advantage & Cataract Surgery
Medicare Advantage (Part C) must provide what is offered by Original Medicare's Part A and Part B, at minimum. Since Part B covers cataract surgery, your Medicare Advantage plan should too. How much is covered and what out-of-pocket costs you might incur will depend on the individual plan you’re enrolled in.
Be sure to check with your insurance provider on copayments or deductibles. You’ll want to ask about:
- The copayment amount for each aspect of the surgery
- Presurgical appointments
- The outpatient procedure itself
- Follow-up appointments
- Post-surgery glasses or contacts
Medicare Advantage plans often provide additional benefits, including vision coverage. Your benefits may help you pay for routine optician appointments and any nonsurgical cataract treatments you try before deciding on cataract surgery.
Because Medicare Advantage plans typically have a prescription drug component bundled in, the medications prescribed before and after the cataract surgery will be covered by that part of the plan — after any applicable deductible. Your out-of-pocket cost will depend on the pricing structure of your individual plan.
Medicare Part D & Cataract Surgery
You may be prescribed some medications to take before or after your cataract surgery, such as antibiotics, steroids, NSAIDs, or prescription eye drops. For example, the American Academy of Ophthalmology reported that 88% of Medicare patients who had cataract surgery were prescribed eye drops.
Original Medicare won't cover those medications, so unless you have a standalone Medicare Part D prescription drug plan, you will have to pay for them out of pocket. But with Part D — if you've met your plan's deductible — you'll only be responsible for your share of the cost based on the pricing structure of your particular Part D plan.
If you have Medicare Advantage, prescription drug coverage is likely bundled into your plan. As with a standalone Part D plan, you will have that plan's deductible to meet first, then your share of the cost for the medication based on your plan's pricing structure.
Medigap & Cataract Surgery
Medicare Supplement (Medigap) insurance is add-on insurance that you buy from a Medicare-approved, private insurer to help pay for what Original Medicare does not: primarily the 20% copayment of any approved charges. Doctors who accept Medicare Part B will also accept your Medigap plan.
Medigap will pay 100%, 75%, or 50% of your Part B copayment, depending on your chosen plan. Without Medigap, you would have to pay 20% of the cost out-of-pocket — but with Medigap, you will pay between $0 and 10% of the cost.
You will be responsible for the Part B deductible ($226 in 2023) unless you are grandfathered into Medigap Plan C or Plan F, which are no longer available to new enrollees.
How Much Does Cataract Surgery Cost?
If your doctor says you need cataract surgery, your first concern might be its cost. Your next thought might be, "Will Medicare pay for cataract surgery?"
Without Medicare insurance, the University of Central Florida College of Medicine reports that you could pay $3,000 to $5,000 per eye for a standard procedure. If you choose an advanced type of surgery — such as laser-assisted — or an advanced lens, the cost will average $4,000 to $6,000 per eye.
On the other hand, using Medicare fees in its calculations, a 2019 article in the Clinical Research in Ophthalmology journal reports that the direct medical cost of cataract surgery was $2,526 for each eye. The calculation was based on average national Medicare Fee Structure costs for the nearly 3.5 million procedures that year.
The U.S. Centers for Medicare & Medicaid Services reports even more affordable pricing. The "Procedure Price Lookup" page of the Medicare website provides standard cataract surgery pricing in two different venues: non-hospital ambulatory surgical centers (where patients aren't expected to need more than 24 hours of care) and hospital outpatient departments.
The average cost in an ambulatory surgical center is $1,606 — $544 for the doctor and $1,062 for the facility. If Original Medicare pays 80%, as the patient, you will pay about $320.
Similar surgeries in hospital outpatient departments are more expensive because of the venue: the average cost is $2,664 — $544 for the doctor and $2,120 for the facility. After Original Medicare pays 80%, you will pay $532.
However, costs can vary significantly depending on the surgeon who performs it, the type of intraocular lens (IOL) used, and the technology employed. It's essential to confirm with your insurance provider that you have remained within their guidelines if you want the maximum costs approved and covered.
With Medicare Advantage, your cost would vary with your specific plan since plans come with many variables: deductibles, copayments, and out-of-pocket maximums. We advise contacting a customer service representative at your insurance provider to identify the various costs, what your plan will pay, and what authorizations are required.
What is the Best Medicare Plan for Cataract Surgery?
Whether you have chosen to stay with Original Medicare or opt for Medicare Advantage, both will help pay for a considerable part of your cataract surgery.
With Original Medicare, most doctors and hospitals will accept Medicare Part B, which covers 80% of your Medicare-approved costs. Most or all of the balance will be covered if you have purchased a Medicare Supplement (Medigap) Plan. For example, as long as you remain within the guidelines of a standard cataract procedure, Medigap Plans F and G will pay the entire bill once you meet any applicable deductible.
Some Medicare Advantage plans will also pay the entire cost of a cataract procedure as long as you remain within your plan's network when choosing your surgeon and surgical facility. If you expect to have cataract surgery in the future, you might want to remember that as you select your plan during the next Medicare Advantage enrollment opportunity. You will want to prioritize low copayments and a robust vision insurance benefit.
If you need help selecting the best plan, contact the licensed insurance agents at OpenMedicare to assist you. Call us at (844) 910-2061, and we'd be happy to answer any questions you may have.
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