Does Medicare Part A and B Cover Cataract Surgery?

Medicare is a federal health insurance program for Americans aged 65 or older and certain younger individuals with disabilities. Understanding its coverage for specific medical procedures, such as cataract surgery, is important for financial planning. Cataract surgery is a common procedure that can significantly improve vision when cataracts cause impairment.

Medicare Part B Coverage for Cataract Surgery

Medicare Part B, which serves as medical insurance, is the primary component of Original Medicare that covers cataract surgery. This coverage extends to both traditional and laser-assisted surgical techniques. The procedure is covered when a physician determines it is medically necessary to correct vision problems caused by cataracts, such as when they impair daily activities like driving or reading.

Part B covers the surgery, including removal of the clouded natural lens and implantation of a standard intraocular lens (IOL). It also covers pre-surgical examinations and diagnostic tests to assess the cataract and plan the surgery.

Anesthesia services, surgeon’s fees, and facility fees for an outpatient surgical center are included. Post-surgical care, such as follow-up appointments and necessary examinations, also falls under Part B coverage.

Medicare Part A and Other Coverage Considerations

Medicare Part A, known as hospital insurance, primarily covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Cataract surgery is almost always outpatient, so Part A generally does not cover it unless an inpatient admission becomes medically necessary, such as due to complications requiring hospitalization. In such rare instances, Part A would cover hospital-related expenses.

While Medicare Part B provides substantial coverage for cataract surgery, it does not cover all available options or enhancements. Premium or advanced technology intraocular lenses (IOLs) are typically not covered. These include multifocal or toric IOLs. If a beneficiary chooses one of these advanced lenses, they will be responsible for the cost difference between the standard IOL and the premium lens.

Medicare has limitations regarding vision correction after surgery. While it generally does not cover routine eyeglasses or contact lenses, Part B makes an exception following cataract surgery. It will cover one pair of standard prescription eyeglasses with basic frames or one set of contact lenses after the intraocular lens has been implanted. Any upgrades or elective enhancements not medically necessary are the patient’s responsibility.

Understanding Your Out-of-Pocket Costs

Even with Medicare Part B coverage, beneficiaries incur out-of-pocket costs for cataract surgery, including a deductible and coinsurance. For 2025, the annual Medicare Part B deductible is $257. This deductible must be met before Medicare pays its share of approved services. Once satisfied, Medicare Part B generally pays 80% of the Medicare-approved amount for covered services.

The remaining 20% of the Medicare-approved amount is the beneficiary’s coinsurance responsibility. This applies to surgeon’s fees, anesthesia, facility charges for outpatient surgery, and all other covered pre- and post-operative care. For instance, if the Medicare-approved amount for the procedure and associated services is $2,000, and the deductible has been met, the beneficiary would pay $400 (20% of $2,000).

Out-of-pocket costs apply only to services Medicare covers. If a beneficiary opts for non-covered items, such as premium intraocular lenses or elective enhancements, they are responsible for the full cost of those items in addition to the deductible and coinsurance for covered services. These additional costs for non-covered services are negotiated directly with the provider and are separate from the Medicare-approved amounts.

Steps to Getting Medicare-Covered Cataract Surgery

Obtaining Medicare-covered cataract surgery involves a series of steps to ensure medical necessity and proper billing. The process begins with a comprehensive eye examination by an ophthalmologist. During this consultation, the doctor evaluates the cataracts’ severity and determines if they significantly impact the patient’s vision and daily activities. This assessment is crucial for establishing medical necessity, a fundamental requirement for Medicare coverage.

The ophthalmologist documents the visual impairment and functional limitations caused by the cataracts. This documentation helps support the medical necessity claim to Medicare. After medical necessity is established, the doctor’s office handles scheduling the surgery and submitting claims. While Original Medicare generally does not require prior authorization for medically necessary cataract surgery, some Medicare Advantage plans may have specific pre-approval requirements.

Patients with Medicare Advantage plans should confirm their plan’s specific rules regarding prior authorization. The doctor’s office typically assists with this process to obtain necessary approvals before the procedure. Once approvals are in place, the surgery can be scheduled. The provider’s office handles billing covered services directly to Medicare, then bills the patient for any remaining deductible, coinsurance, or non-covered costs.