Does Medicare Pay for Cataract Surgery?

Medicare generally covers cataract surgery when a healthcare provider determines it is medically necessary. This coverage helps individuals manage costs associated with restoring vision impacted by cataracts. Understanding specific aspects of Medicare coverage is helpful for beneficiaries considering this common procedure.

General Medicare Coverage for Cataract Surgery

Medicare Part B, which is medical insurance, primarily covers cataract surgery. This includes both traditional and laser-assisted surgical techniques. Coverage depends on medical necessity, meaning a doctor must confirm the cataract significantly impairs vision and interferes with daily activities like reading, driving, or working.

Medical necessity is based on how a cataract affects a patient’s functional vision and quality of life. If visual impairment cannot be corrected with glasses or contacts and impacts daily tasks, the surgery is typically deemed medically necessary. Medicare aims to cover procedures that prevent, diagnose, treat, or cure a medical condition.

Detailed Coverage of Services

Medicare Part B covers services related to medically necessary cataract surgery. This includes pre-operative exams to assess eye health, the cataract removal procedure, and implantation of a standard intraocular lens (IOL). Post-operative care and follow-up visits are typically covered. Medicare also covers one pair of prescription eyeglasses with standard frames or a set of contact lenses after surgery, which is an exception to its usual vision correction policy.

Medicare does not cover all types of lenses or elective components of the surgery. Premium or advanced intraocular lenses, such as multifocal or toric IOLs, are generally not covered. These advanced lenses offer additional benefits like correcting astigmatism or providing vision at multiple distances. Patients choosing them will be responsible for the cost difference between a standard IOL and the premium lens. Medicare’s coverage focuses on restoring functional vision, not on elective enhancements or refractive surgery components.

Your Financial Responsibilities

Beneficiaries with Original Medicare (Parts A and B) will incur out-of-pocket costs for cataract surgery. After meeting the annual Medicare Part B deductible ($257 in 2025), individuals are responsible for a 20% coinsurance of the Medicare-approved amount for the surgery and related services. For example, if the Medicare-approved amount for a procedure is $2,000, the coinsurance would be $400 after the deductible is met.

Medicare Advantage (Part C) plans also cover medically necessary cataract surgery, as they must provide at least the same benefits as Original Medicare. These plans are offered by private companies and may have different cost-sharing structures, such as copayments instead of coinsurance, and may require patients to use in-network providers. Some Medicare Advantage plans may offer additional vision benefits beyond what Original Medicare provides.

Medicare Supplement Insurance (Medigap) plans can help cover some of the out-of-pocket expenses associated with Original Medicare, including the 20% Part B coinsurance and the Part B deductible. These plans are sold by private insurers and can significantly reduce a beneficiary’s financial responsibility for covered services. Medigap plans do not cover premium IOLs or services not covered by Original Medicare.

Steps to Accessing Covered Care

The process for receiving Medicare-covered cataract surgery begins with a visit to an ophthalmologist. During this visit, the ophthalmologist will conduct a comprehensive eye examination to diagnose the cataract and determine if it is medically necessary for surgery based on its impact on vision and daily activities. Confirm that the chosen healthcare provider and facility accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment for services.

Once medical necessity is established, the ophthalmologist’s office will typically handle the necessary paperwork and submit claims to Medicare. Some Medicare Advantage plans may require prior authorization before the surgery can proceed, which can sometimes delay the process. Beneficiaries should discuss all aspects of the procedure, including potential out-of-pocket costs and the type of intraocular lens to be implanted, with their doctor and the billing department before scheduling the surgery.