Does Medicare Cover Cataract Surgery?

Medicare provides healthcare coverage for millions of Americans, particularly seniors and individuals with certain disabilities. Cataracts, the clouding of the eye’s natural lens, become common with age, affecting over half of Americans aged 80 or older. This condition can significantly impair vision and daily activities. Understanding how Medicare addresses cataract surgery is important for beneficiaries navigating their healthcare options.

Medicare Coverage Criteria

Medicare covers cataract surgery when a licensed ophthalmologist determines the procedure is medically necessary. The cataract must significantly impair vision and affect daily activities like driving, reading, or watching television.

Medicare Part B, which covers outpatient medical services, provides coverage for cataract surgery. This includes the pre-operative exams necessary to diagnose the condition and confirm medical necessity. While Medicare does not cover routine vision care, it covers cataracts when treatment is required.

Covered Surgical Procedures

Medicare covers both traditional and laser-assisted cataract surgery when medically necessary. These procedures involve the removal of the cloudy natural lens and its replacement with an artificial intraocular lens (IOL). The choice of surgical technique, traditional or laser, does not affect Medicare’s payment amount.

Medicare covers the cost of a standard monofocal IOL. These basic lenses provide clear vision at a single focal point, usually for distance vision. Premium IOLs, such as toric lenses for astigmatism or multifocal/accommodative lenses, are not fully covered. Patients opting for these advanced lenses will incur additional out-of-pocket costs beyond what Medicare covers for a standard lens.

Patient Financial Obligations

Cataract surgery costs for Original Medicare (Parts A and B) typically fall under Medicare Part B. After the annual Part B deductible is met, Medicare covers 80% of the Medicare-approved amount for the surgery. This means the patient is responsible for the remaining 20% coinsurance. The deductible amount can change annually.

Supplemental insurance plans, such as Medicare Supplement (Medigap) policies, can help cover some or all of the patient’s out-of-pocket expenses, including the 20% coinsurance. Medicare Advantage (Part C) plans, offered by private insurers, must cover at least the same services as Original Medicare, but may have different cost-sharing rules, such as fixed copayments, and may require using in-network providers. Patients should consult their specific plan for details on their financial responsibility.

Post-Operative Care and Items

Medicare Part B also covers necessary post-operative care following cataract surgery. This includes follow-up appointments with the surgeon to monitor recovery and address any complications. These visits are typically covered for up to 90 days after the procedure.

Medicare makes an exception to its general rule of not covering eyeglasses or contact lenses after cataract surgery. Medicare Part B covers one pair of standard prescription eyeglasses or one set of contact lenses if prescribed after cataract surgery that implants an intraocular lens. This coverage is for standard frames and lenses; any upgrades, such as designer frames or special coatings, will result in additional out-of-pocket costs for the patient. Routine eye exams unrelated to the surgery, or for purposes other than correcting vision after an IOL implant, remain uncovered by Original Medicare.