Does Medicare Cover Cataract Surgery?
Navigate Medicare's coverage for cataract surgery. Get clear insights into what's covered, your financial responsibilities, and how different plans apply.
Cataract surgery is a common and effective medical procedure that restores vision by addressing cloudy areas in the eye’s lens. Understanding how Medicare covers this procedure is important for beneficiaries planning their vision care needs. The coverage details can influence financial planning and access to care.
Medicare Part B Coverage for Cataract Surgery
Original Medicare, specifically Part B, covers medically necessary cataract surgery. A procedure is considered medically necessary when a healthcare provider determines it is required to treat a medical condition, such as vision impaired by cataracts. This means the surgery is not for purely cosmetic reasons or elective vision correction.
Medicare Part B covers outpatient medical services and supplies. Since cataract surgery is typically performed in an outpatient setting, it falls under Part B’s scope. This coverage extends to the surgical procedure itself, as well as related services.
Covered Services and Items
Medicare Part B covers a range of services and items associated with medically necessary cataract surgery. This includes initial pre-operative examinations and diagnostic tests to determine the surgery’s necessity. These assessments help the ophthalmologist plan the procedure.
The surgical procedure itself, including the removal of the cloudy lens and the implantation of a standard intraocular lens (IOL), is covered. A standard IOL is a monofocal lens that corrects vision for one focal point, typically distance. Post-operative care, such as follow-up visits and necessary medications related to recovery, are also included.
While standard IOLs are covered, premium or advanced-technology IOLs are generally not fully covered by Medicare. These include multifocal or toric lenses that offer additional vision benefits. If a beneficiary chooses a premium IOL, they are responsible for the difference in cost. Elective refractive procedures performed at the time of cataract surgery are not covered unless medically indicated.
Your Out-of-Pocket Costs
Beneficiaries with Original Medicare Part B are responsible for certain out-of-pocket costs for medically necessary cataract surgery. You must first meet the annual Part B deductible. For example, in 2024, the Part B deductible is $240.
After satisfying the deductible, Medicare typically pays 80% of the Medicare-approved amount for covered services. You are responsible for the remaining 20% coinsurance. This 20% coinsurance applies to surgeon’s fees, facility fees, and the cost of the standard intraocular lens.
Some beneficiaries choose to enroll in a Medicare Supplement Insurance (Medigap) plan to help cover these expenses. Medigap plans work alongside Original Medicare to pay for deductibles, copayments, and coinsurance. However, Medigap plans do not cover the additional costs associated with premium intraocular lenses.
Cataract Surgery Through Medicare Advantage Plans
Medicare Advantage Plans, also known as Part C, offer an alternative way to receive Medicare benefits. These plans are provided by private insurance companies approved by Medicare and are required to cover at least all services Original Medicare covers, including medically necessary cataract surgery.
While Medicare Advantage plans must cover the same services, their cost-sharing rules can differ significantly from Original Medicare. These plans may have their own deductibles, copayments, or coinsurance amounts for cataract surgery, which can vary widely by plan.
Medicare Advantage plans often operate with provider networks. You might need to receive care from doctors and facilities within the plan’s network for full coverage. Many plans also require prior authorization for certain procedures. Beneficiaries should contact their plan provider to understand their specific coverage, costs, and authorization requirements.