Does Medicare Pay for Cataract Surgery?
Does Medicare cover cataract surgery? Understand what's covered, your costs, and how different Medicare plans impact your procedure.
Cataract surgery is a common procedure that can significantly improve vision when cataracts cause cloudiness in the eye’s natural lens. Medicare generally covers medically necessary cataract surgery, though specific conditions and financial responsibilities apply.
Understanding Medicare Coverage
Medicare Part B covers outpatient cataract surgery when deemed medically necessary by an ophthalmologist. This coverage includes surgeon’s fees, facility fees for an ambulatory surgical center or hospital outpatient department, anesthesia, and a standard intraocular lens (IOL) implant.
Coverage also includes services part of the global surgical package, such as pre-operative examinations and post-operative care for up to 90 days. While most cataract surgeries are outpatient, Medicare Part A might cover an inpatient hospital stay if medical necessity arises due to significant complications.
Medicare does not cover advanced or premium intraocular lenses, such as toric or multifocal lenses. If a patient chooses one of these upgraded lenses, they are responsible for the additional cost beyond what Medicare would pay for a standard IOL.
Anticipating Your Out-of-Pocket Costs
When cataract surgery is covered by Original Medicare (Part A and Part B), beneficiaries are responsible for out-of-pocket costs. For Part B services, the annual deductible must first be met. In 2025, this Part B deductible is $257. After the deductible is met, Medicare pays 80% of the approved amount for covered services, leaving the beneficiary responsible for the remaining 20% coinsurance.
This 20% coinsurance applies to surgeon’s fees, facility fees, anesthesia, and the standard intraocular lens. For example, if the approved amount for outpatient surgery is $2,000 and the deductible is met, the beneficiary would pay $400. If a medically necessary inpatient hospital stay is required and covered by Part A, a separate Part A deductible of $1,676 per benefit period applies in 2025. For extended hospital stays, daily coinsurance amounts are incurred: $419 per day for days 61 through 90, and $838 per day for lifetime reserve days beyond 90 days.
Beyond these standard cost-sharing amounts, beneficiaries are responsible for any costs not covered by Medicare. Medicare Part B provides coverage for one pair of standard prescription eyeglasses or one set of contact lenses after cataract surgery with an IOL implant. Costs for upgraded or designer frames, or for ongoing replacements beyond this initial pair, are not covered.
Navigating the Coverage Process
It is advisable to choose a healthcare provider and facility that accept Medicare assignment. When a provider accepts assignment, they agree to accept the Medicare-approved amount as full payment for covered services. Providers who do not accept assignment may charge up to 15% more than the Medicare-approved amount, known as a limiting charge, and may require full payment at the time of service.
The ophthalmologist documents the medical necessity of the cataract surgery. This confirms the condition significantly affects daily activities and the procedure is required to correct it. While pre-authorization is not always required for standard cataract surgery under Original Medicare, confirm any requirements with the provider, especially if a Medicare Advantage plan is involved.
Providers handle claims submission directly to Medicare. After processing, beneficiaries receive a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) from their Medicare Advantage plan. Reviewing these documents helps understand what Medicare paid and what remains the patient’s financial responsibility.
Impact of Other Medicare Plans
Medicare Advantage Plans are offered by private insurance companies approved by Medicare. These plans must cover all services Original Medicare covers. Medicare Advantage plans may have different cost-sharing structures, such as copayments instead of coinsurance, and often require beneficiaries to use providers within a specific network. Individuals enrolled in a Medicare Advantage plan should check their specific plan’s benefits, provider network, and any pre-authorization requirements before surgery.
Medigap policies work in conjunction with Original Medicare. These private insurance plans help cover some of the out-of-pocket costs Original Medicare does not, such as the Part B deductible and the 20% coinsurance. Different Medigap plans offer varying levels of coverage for these expenses, which can significantly reduce a beneficiary’s financial responsibility for covered cataract surgery.
Medicare Part D provides prescription drug coverage. It can cover prescription medications, such as eye drops needed before or after cataract surgery. These plans are offered by private companies and vary in their formularies and cost-sharing for different medications.