Does Medicare Part A Cover Cataract Surgery?

Medicare is a federal health insurance program that helps millions of Americans with healthcare costs. Understanding its coverage, especially for common procedures like cataract surgery, is important for financial planning. The program is divided into different parts, each covering specific types of services.

Medicare Part A and Cataract Surgery

Medicare Part A, or Hospital Insurance, primarily covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Part A typically does not cover cataract surgery itself, as it is usually an outpatient procedure. Coverage would only apply under specific, unusual circumstances, such as severe complications requiring an inpatient hospital admission. In such cases, Part A would help cover hospital-related expenses.

Medicare Part B and Cataract Surgery

Medicare Part B, or Medical Insurance, covers medically necessary outpatient services, including doctor visits, diagnostic tests, and outpatient surgeries. It specifically covers cataract surgery when medically necessary. Coverage extends to the surgeon’s fees, facility fees for ambulatory surgical centers or hospital outpatient departments, and anesthesia. Part B also covers a standard intraocular lens (IOL) implant.

After the annual Medicare Part B deductible is met, Medicare generally pays 80% of the Medicare-approved amount for these covered services. For 2025, the annual Part B deductible is $257. The patient is then responsible for the remaining 20% coinsurance. This coinsurance applies to the surgeon’s fees, facility charges, and anesthesia. Additionally, Part B may cover one pair of prescription eyeglasses with standard frames or a set of contact lenses after the surgery.

Understanding Out-of-Pocket Expenses

Even with Medicare Part B coverage, individuals will still incur some out-of-pocket expenses for cataract surgery. The first expense is the annual Medicare Part B deductible, which must be satisfied before Medicare begins to pay its share. Once the deductible is met, the patient is responsible for 20% coinsurance of the Medicare-approved amount for the covered services, such as surgeon fees and facility charges. For instance, if the Medicare-approved amount for a procedure is $2,000, the patient’s 20% coinsurance would be $400 after meeting the deductible.

A significant out-of-pocket cost can arise if a patient chooses a premium intraocular lens (IOL). Medicare only covers a basic, standard monofocal IOL. If a patient opts for an advanced lens, such as a toric lens to correct astigmatism or a multifocal lens for vision at multiple distances, Medicare will not cover the additional cost of these upgrades. The patient is responsible for the full difference in cost between the standard IOL and the chosen premium IOL.

Medicare Advantage and Medigap Plans

Medicare Advantage Plans, also known as Part C, are offered by private companies approved by Medicare. These plans must provide at least the same coverage as Original Medicare (Parts A and B), which includes medically necessary cataract surgery. However, Medicare Advantage plans may have different cost-sharing structures, such as copayments or coinsurance, and may require prior authorization for certain services. They often operate with provider networks, meaning services may need to be received from in-network providers for coverage to apply.

Medigap policies, or Medicare Supplement Insurance, are designed to help pay some of the out-of-pocket costs that Original Medicare does not cover. These policies can assist with expenses like deductibles, copayments, and coinsurance for Part A and B services, including those related to cataract surgery. Depending on the specific Medigap plan selected, it can cover the 20% coinsurance that remains after Medicare Part B pays its share, potentially reducing the patient’s out-of-pocket responsibility significantly.