Does Medicare Pay for Cataract Surgery?

Cataract surgery is a common procedure that restores vision by replacing a clouded natural lens. As cataracts frequently develop with age, Medicare, a federal health insurance program, covers medically necessary cataract surgery.

Understanding Medicare Coverage

Cataract surgery coverage primarily falls under Original Medicare, specifically Part B, which addresses outpatient medical services. If a hospital stay becomes medically necessary due to complications, Medicare Part A, which covers inpatient hospital care, would then apply.

Medicare Advantage Plans, also known as Part C, offer an alternative to Original Medicare and are provided by private companies approved by Medicare. These plans are required to cover at least the same benefits as Original Medicare, including cataract surgery. However, Medicare Advantage plans may have different rules, such as network requirements or varying cost-sharing structures.

Medical necessity is a requirement for Medicare coverage of cataract surgery under any plan. This means a doctor must determine that the cataract significantly impairs vision and affects daily activities, such as driving, reading, or working. Coverage is not solely based on the presence of a cataract but on its impact on the patient’s functional abilities.

Specific Services Covered

Medicare covers the surgical procedure itself, which involves the removal of the clouded lens and the implantation of a new one. Pre-operative exams, anesthesia administered during the surgery, and post-operative care are also covered services.

Medicare’s coverage for the replacement lens is generally limited to a standard intraocular lens (IOL). These are typically monofocal lenses designed to provide clear vision at a single distance, often set for distance viewing. Patients receiving a standard IOL may still require eyeglasses for near or intermediate vision tasks.

Medicare generally does not cover premium, multifocal, or toric IOLs, which are designed to correct astigmatism or provide vision at multiple distances. If a patient opts for one of these advanced lenses, they are responsible for the additional cost beyond what Medicare covers for a standard IOL. This distinction applies because the enhanced features of these lenses are not considered medically necessary for vision restoration.

After the surgery, Medicare Part B also covers one pair of prescription eyeglasses with standard frames or one set of contact lenses. This is a specific exception to Medicare’s general policy of not covering routine vision care. The covered eyewear must be obtained from a Medicare-enrolled supplier.

Your Out-of-Pocket Costs

Under Original Medicare Part B, beneficiaries are responsible for certain out-of-pocket costs related to cataract surgery. In 2025, after meeting the annual Part B deductible, which is $257, you typically pay 20% of the Medicare-approved amount for the surgery and related services.

For example, if the Medicare-approved amount for a cataract procedure is $2,000, after meeting your deductible, you would be responsible for $400 (20% of $2,000). This 20% coinsurance applies to the surgeon’s fees, facility charges, and the standard intraocular lens. The total cost can vary depending on the facility, such as a surgical center versus a hospital outpatient department.

Medigap policies, also known as Medicare Supplement Insurance, can help cover some of these out-of-pocket expenses. These private insurance plans work with Original Medicare to pay for costs like the Part B deductible and coinsurance. Depending on the specific Medigap plan, it may cover nearly all of the remaining 20% coinsurance, significantly reducing your financial responsibility.

Medicare Advantage plans have different cost-sharing structures that vary by plan. These plans may charge copayments or coinsurance for cataract surgery, which could be a fixed dollar amount rather than a percentage. Review your specific Medicare Advantage plan’s Summary of Benefits and Coverage to understand your potential financial obligations.

Navigating the Coverage Process

The process for obtaining Medicare coverage for cataract surgery begins with a consultation with an eye doctor, typically an ophthalmologist. The doctor will perform a comprehensive eye examination to diagnose the cataract and determine if it is medically necessary for surgery.

Once medical necessity is confirmed, the doctor’s office plays a central role in the administrative process. They will submit claims to Medicare for the procedure and related services. For those with a Medicare Advantage plan, the doctor’s office may need to obtain pre-authorization before the surgery can proceed.

Ensuring that your chosen healthcare provider and facility are Medicare-approved is a practical step to confirm coverage. Patients should discuss the estimated costs and their potential financial responsibility with their provider’s billing department. After the surgery, Medicare will process the claims, and you will receive an Explanation of Benefits (EOB) detailing the services billed and the amounts covered by Medicare, along with your remaining balance.