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Does Medicare Pay for Cataract Surgery? How to Qualify

What are cataracts? 

Cataracts occur when the lens of your eye becomes clouded and hard to see through, which can happen in either eye. This causes it to seem like you’re looking through a fogged window that can not only make your vision cloudy, but can also affect how you see colors and light.

cataract surgeon doing an exam

Though the cause of cataracts is yet unknown, it is believed that proteins in the lens of the eye breaking down over time may produce them.

And, there is good news for those wondering if Medicare covers cataract surgery, since they may indeed be able to help cover the costs of your surgical treatment.

Does Medicare cover cataract surgery?

Though Medicare doesn’t pay for most vision care, it does cover necessary services such as cataract surgery.

This includes:

  • Removing the cataract
  • Implanting a new lens
  • Eyeglasses or contact lenses for use after the surgery

While Medicare covers these basics of regular surgeries, they may not be able to cover more advanced treatments .

How do I qualify?

If you’re 65-or older and your doctor has determined surgery for your cataracts to be medically necessary, Medicare will typically cover 80% of your expenses including post-surgery eyeglasses or contacts.

While coverage often varies from region-to-region and between local carriers, so as long as your doctor accepts Medicare as payment, you’re covered for cataract surgery.

Original Medicare, Medicare Advantage, and Medigap offer different coverages

Once you’ve met your deductible, Medicare Part B will cover 80% of the cost of your surgery. Though it’s rare for hospitalization to be required for this type of surgery, if it’s deemed necessary, Medicare Part A will cover it as well.

Medicare Advantage and Medigap supplemental insurance may also offer lower out-of-pocket costs and encompass more elaborate treatments for you, though it’s likely that your choice of providers will be limited under these plans.

How much does Medicare cover?

Once it’s determined by your doctor that surgery is necessary for your cataracts, Medicare will normally cover 80% of the costs. This includes all preoperative and postoperative exams, surgical removal of the cataract, implantation of the new lens, and a pair of eyeglasses or contacts.

Though Medicare normally doesn’t pay for eyeglasses or contact lenses, one post-operative pair is the only exception.

How much does cataract surgery cost?

In 2020, the average cost of cataract surgery was $2578 per-eye at an outpatient hospital facility, with the cost at a standalone surgery center being about $1000 less. Most of the cost is the facility fee ($2021 for hospital outpatients; $1012 at a surgery center), with the doctor’s fee being the same at $557.

Depending on the particular needs of your case and its complexity, your costs may be higher or lower than this, though Medicare will usually cover 80% of it. For example, for an outpatient treatment, Medicare would cover $2063 of the cost, leaving a co-payment of $515 as your out-of-pocket fee.

Does Medicare cover other costs associated with cataract surgery?

Though Medicare covers 80% of most of the costs of cataract surgery involving intraocular lens implants, more advanced treatments may require you to cover a greater percentage, or even all of the cost.

Medicare will cover one pair of glasses after your surgery, though things like updated frames, additional pairs of contact lenses, or other items associated with the treatment such as eye drops likely won’t be covered. It’s also important that you speak to your healthcare provider about what specifically is, and is not, covered under your plan to avoid unexpected costs.

What are the exclusions?

Though Medicare will cover both laser and traditional cataract surgeries, they do not yet cover New Technology Intraocular Lenses (NTIOLS). For instance, Medicare may not cover you if you need multifocal or toric lenses, though they will cover monofocal lenses.

You are also responsible for the 20% Medicare doesn’t pay on standard treatments, as well as all deductibles and medications.

What are the roles of a Medicare Supplemental Plan?

Along with Original Medicare, Medigap or Medicare Advantage,  which are plans from private insurers that anyone 65-or-older with Medicare parts A & B may apply for, may be used to extend your coverage.

For instance, premium cataract surgery such as to repair an astigmatism or presbyopia may not be fully covered by Medicare. However, Medigap may be able to help cover the cost, which can be as much as 3-times that of standard cataract surgery.

There’s also Medicare Advantage, which is a plan that replaces Medicare Parts A & Part B, and may cover standard vision care (such as for a routine prescription to contact lenses or glasses), as well as other expenses not covered under Medicare Parts A & B.

The cost of these plans may vary, and while they typically offer lower out-of-pocket expense, your choice of physicians under them may be limited.

When should I see a doctor?

Cataracts aren’t always noticeable in their early stages, which is why it’s best to schedule regular visits with your eye doctor for early detection.

But, if you do experience any of the following symptoms, it’s time to visit your doctor:

  • Blurry vision
  • Clouded vision
  • Seeing halos around lights
  • Double vision
  • Indistinct differences between colors

So, does Medicare pay for cataract surgery? Yes, once your deductible and co-payment are met, Medicare can cover the rest and keep your treatment affordable for you.

Why Intermountain Healthcare?

At Intermountain Healthcare, we are dedicated to providing high-quality healthcare in the heart of our communities. Use our Find a Provider tool today to find a doctor close to home and ready to meet with you.

*Please check with your plan for more information on details of your benefits coverage. This article is for informational purposes only and is not intended to be a substitute for medical advice or diagnosis from a physician or qualified healthcare professional.

 

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