Does Medicare Cover Cataract Surgery?
Navigate the complexities of Medicare coverage for cataract surgery. Understand what's covered, your potential costs, and how different plans affect your benefits.
Cataract surgery involves removing a clouded natural lens from the eye and typically replacing it with a clear artificial lens, known as an intraocular lens (IOL). This common procedure helps to restore vision impaired by cataracts, which can cause blurry vision and, if left untreated, may lead to blindness. Medicare generally covers medically necessary cataract surgery.
Original Medicare Coverage for Cataract Surgery
Original Medicare, which includes Part A and Part B, provides coverage for cataract surgery. Since most cataract surgeries are performed in an outpatient setting, Medicare Part B is the primary source of coverage. This includes the surgical procedure itself, whether traditional or laser-assisted, and the implantation of a standard intraocular lens.
Medicare Part B also covers essential services surrounding the surgery. This includes pre-operative eye exams and diagnostic tests, the use of the operating room, anesthesia, and the surgeon’s fees. Following the procedure, Medicare Part B covers post-operative care, including follow-up visits for up to 90 days. If an inpatient hospital stay is medically necessary due to complications, Medicare Part A would cover those hospitalization costs.
Your Costs with Original Medicare
Individuals with Original Medicare will incur out-of-pocket expenses for cataract surgery. After meeting the Medicare Part B deductible, beneficiaries pay 20% of the Medicare-approved amount for covered services. This coinsurance applies to the surgeon’s fees, facility charges, and other covered medical services.
Costs vary depending on where the procedure is performed, such as an ambulatory surgical center or a hospital outpatient department. If a complication necessitates an inpatient hospital stay, the Medicare Part A deductible would apply, in addition to any Part B costs.
Medicare Advantage and Other Options
Medicare Advantage (Part C) plans also cover cataract surgery, as they are required to cover at least what Original Medicare covers. However, Medicare Advantage plans, offered by private companies, may have different cost-sharing structures. This can include specific copayments for the procedure, varying deductibles, and an out-of-pocket maximum that limits annual spending. It is important to review the specific plan details, as costs can depend on the plan’s network and specific benefit design.
Individuals with Medigap (Medicare Supplement Insurance) policies can receive assistance with their out-of-pocket costs under Original Medicare. Medigap plans help cover expenses like the Medicare Part B deductible and the 20% coinsurance that Original Medicare does not pay. Depending on the specific Medigap plan selected, an individual’s out-of-pocket costs for medically necessary cataract surgery could be significantly reduced or even eliminated.
What Medicare Does Not Cover
While Medicare covers medically necessary cataract surgery, it does not cover all related expenses, particularly for elective upgrades or certain types of lenses. Medicare covers the cost of a standard monofocal intraocular lens (IOL) implant, which provides vision correction at a single focal distance. However, premium or advanced technology IOLs, such as multifocal, toric (for astigmatism), or accommodative lenses, are generally not covered.
If an individual chooses one of these advanced lenses, they will be responsible for the cost difference between the standard covered lens and the upgraded option. Similarly, Medicare does not cover elective refractive surgery if its primary purpose is vision correction unrelated to the cataract removal. While Medicare Part B does cover one pair of standard eyeglasses or contact lenses after cataract surgery, it does not cover designer frames or additional pairs beyond the initial set.