Does Medicare Cover Cataract Surgery for Seniors?

Cataracts are a common age-related condition, often leading to clouded or blurry vision. Understanding how Medicare, the federal health insurance program for people aged 65 or older, covers cataract surgery is important for beneficiaries. This article clarifies Medicare’s role in covering this eye procedure.

Original Medicare Coverage

Cataract surgery is covered by Original Medicare when a physician determines it is medically necessary to improve vision or treat an eye condition. Medical necessity is a requirement for coverage, ensuring the procedure addresses a health concern. Medicare defines medically necessary services as those needed to diagnose or treat an illness, injury, condition, disease, or its symptoms.

Most cataract surgeries are performed on an outpatient basis, meaning the patient does not require an overnight hospital stay. In these scenarios, Medicare Part B, which covers medical services and outpatient care, is the primary component. If an inpatient hospital stay becomes medically necessary for the surgery, Medicare Part A, which covers hospital insurance, applies. Medicare covers the removal of the clouded lens and its replacement with a standard intraocular lens (IOL).

Specifics of Coverage and Out-of-Pocket Costs

Once medical necessity for cataract surgery is established, Medicare Part B covers a significant portion of the approved costs. Beneficiaries are responsible for meeting the annual Part B deductible before Medicare begins to pay its share. For 2025, the annual Part B deductible is $257.

After the deductible is met, Medicare Part B pays 80% of the Medicare-approved amount for the surgery. The beneficiary is responsible for the remaining 20% coinsurance. This 20% coinsurance applies to services associated with the procedure, including the surgery, facility fees, anesthesia, and the surgeon’s professional fees.

Medicare Part B also covers pre-operative exams related to the cataract diagnosis and post-operative care, including follow-up visits for up to 90 days after the procedure. Medicare will cover one standard pair of prescription eyeglasses or one set of contact lenses following cataract surgery that implants an IOL.

Medicare Advantage Plans and Advanced Options

Medicare Advantage Plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare and provide an alternative way to receive Medicare Part A and Part B benefits. These plans are required to 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, deductibles, and out-of-pocket maximums, which can vary between plans.

Beneficiaries enrolled in a Medicare Advantage plan may need to use healthcare providers and facilities within the plan’s network to ensure the lowest out-of-pocket costs. While the medically necessary portion of the surgery and a standard monofocal intraocular lens are covered by both Original Medicare and Medicare Advantage plans, advanced intraocular lenses, such as multifocal, toric, or accommodative IOLs, are not fully covered. These advanced lenses can correct astigmatism or presbyopia, potentially reducing the need for glasses after surgery.

If a patient chooses an advanced IOL, Medicare will still cover the cost of a standard IOL and the associated surgical services. However, the additional cost for the premium features of the advanced lens is an out-of-pocket expense for the patient. This cost must be paid by the patient if they opt for these upgraded lenses.

Preparing for Cataract Surgery Coverage

Consulting with an ophthalmologist is the first step to ensure the procedure is medically necessary for your condition, which is a prerequisite for Medicare coverage. The medical necessity documentation from the physician is crucial for Medicare to approve payment.

It is important to confirm that both the surgeon and the surgical facility accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment for services. For those with a Medicare Advantage plan, inquire about any pre-authorization requirements, as some plans mandate prior approval. Beneficiaries should ask their provider for an “Advanced Beneficiary Notice of Noncoverage” (ABN) if a service is not expected to be covered. An ABN informs the patient that Medicare may not pay for a specific service or item, clarifying their financial responsibility before the service is rendered.