Does Medicare Cover Cataract Eye Surgery?

Cataracts, a common age-related eye condition, involve the clouding of the eye’s natural lens, leading to blurry vision, increased glare, and difficulty with daily activities. This condition affects millions, particularly those over 80, with many eventually undergoing surgery. Understanding Medicare coverage for cataract surgery is important for beneficiaries, as it impacts financial planning.

Medicare Part B Coverage for Cataract Surgery

Medicare Part B, which is medical insurance, generally covers medically necessary cataract surgery. This coverage extends to the surgical procedure itself, including the removal of the cloudy lens and the implantation of a standard intraocular lens (IOL). Services such as pre-operative exams, anesthesia, and post-operative care are included. Medicare also covers one pair of prescription eyeglasses with standard frames or a set of contact lenses after the surgery, which is an exception to its usual policy on vision care.

For Medicare to consider cataract surgery medically necessary, the cataract must cause symptomatic visual impairment uncorrectable with glasses or contacts. This impairment should limit daily activities like reading, driving, or watching television. An ophthalmologist’s documentation is required, showing the cataract is the primary cause of visual compromise and that the patient desires surgery after understanding the risks and benefits.

Understanding Your Out-of-Pocket Costs

Under Original Medicare, beneficiaries pay certain out-of-pocket costs for covered cataract surgery. For 2025, individuals must first meet the Medicare Part B annual deductible of $257. After the deductible, Medicare Part B covers 80% of the approved amount for surgery and related services. The beneficiary is responsible for the remaining 20% coinsurance.

Additional costs arise if a beneficiary chooses a non-standard or premium intraocular lens (IOL). Medicare covers a basic, single-focus (monofocal) IOL, but not the added costs for advanced lenses correcting astigmatism or providing multifocal vision. If a premium lens is selected, the patient pays the cost difference between the standard IOL and the upgraded lens, including any related surgical fees or diagnostic services not covered by Medicare.

How Medicare Advantage and Medigap Plans Affect Coverage

Medicare Advantage Plans (Part C) offer an alternative to Original Medicare through private insurance companies. These plans must cover at least the same services as Original Medicare, including medically necessary cataract surgery. However, Medicare Advantage plans may have different cost-sharing structures, such as copayments instead of the 20% coinsurance. They may also require in-network providers or prior authorization, affecting out-of-pocket expenses and access to care.

Medigap (Medicare Supplement Insurance) policies help cover out-of-pocket costs left by Original Medicare. These private plans can help pay for the Part B deductible and the 20% coinsurance for Medicare-approved services, including cataract surgery. Depending on the Medigap plan selected, a beneficiary’s out-of-pocket costs for cataract surgery could be significantly reduced, potentially to very little or nothing, after the Part B deductible is met.

Steps to Getting Medicare-Covered Cataract Surgery

The process for obtaining Medicare-covered cataract surgery begins with an initial consultation and diagnosis by an ophthalmologist. The doctor assesses the severity of cataracts and determines if they cause significant visual impairment that interferes with daily life.

Once medical necessity is confirmed, choose a surgeon and facility that accept Medicare assignment. This ensures the provider accepts the Medicare-approved amount as full payment. For those with a Medicare Advantage plan, check if prior authorization is required, as some plans may mandate approval before surgery. After these steps, the surgery can be scheduled, and follow-up appointments planned by the surgical team.