What Part of Cataract Surgery Is Not Covered by Insurance?

Cataract surgery is a common medical procedure designed to restore clear vision by removing a clouded natural lens and replacing it with an artificial intraocular lens (IOL). This procedure is frequently considered medically necessary when cataracts significantly impair a person’s vision and daily activities. Understanding the financial aspects of cataract surgery, including what health insurance plans typically cover and potential out-of-pocket expenses, is important. Health insurance, rather than vision insurance, generally covers cataract surgery, as it is a medical intervention.

Standard Cataract Surgery Coverage

Most health insurance plans, including Medicare and private insurers, cover the core components of cataract surgery when it is medically necessary. This includes the basic surgical procedure, which aims to restore functional vision.

A standard monofocal intraocular lens (IOL) implant is also covered by insurance. This type of lens corrects vision at a single distance, either near or far, meaning patients may still need glasses for other distances after surgery. Medicare Part B, for instance, covers a standard IOL implant and pays 80% of the Medicare-approved amount after the annual deductible is met, leaving the patient responsible for the remaining 20% coinsurance.

Beyond the surgical procedure and the standard lens, insurance coverage extends to necessary pre-operative and post-operative medical appointments. This includes initial assessments with the cataract surgeon and follow-up visits after the procedure. Additionally, the costs associated with the surgical facility and any anesthesia administered during the procedure are covered as part of the medically necessary treatment.

Non-Covered Aspects and Upgrades

While standard cataract surgery is largely covered, several aspects and upgrades are not fully covered by insurance, leading to out-of-pocket costs for the patient. One example is the choice of premium intraocular lenses (IOLs) over the standard monofocal lens. These advanced lenses, such as multifocal, toric (for astigmatism), or extended depth of focus (EDOF) IOLs, offer enhanced visual benefits like reduced dependence on glasses for multiple distances or astigmatism correction.

Insurance companies consider these premium IOLs elective enhancements because a standard monofocal lens is sufficient to restore basic functional vision. Patients opting for a premium IOL pay the additional cost for the lens out-of-pocket, which can range from $2,500 per eye more than standard options. The total cost for the procedure with premium IOLs can rise to between $4,000 and $7,000 per eye.

Another upgrade not covered is Laser-Assisted Cataract Surgery (LACS). While LACS may offer benefits such as greater precision in certain surgical steps, it is viewed by insurers, including Medicare, as an elective procedure rather than a medical necessity. Patients choosing LACS incur additional out-of-pocket expenses, which can add $1,000 to $2,500 per eye to the overall cost, depending on the provider and specific technology used.

Some diagnostic tests or technologies used for planning premium lens implantation or LACS, which are not considered medically necessary for basic cataract removal, may be out-of-pocket expenses. For example, certain advanced imaging or wavefront analysis systems used to optimize outcomes for premium lenses might not be covered.

Understanding Your Insurance’s Role in Costs

Even for covered services, an individual’s health insurance plan influences the final out-of-pocket costs through various mechanisms. A deductible is the amount an insured person must pay for covered healthcare services before their insurance coverage begins to pay. For individual plans, average annual deductibles can range from $1,787 for employer-provided coverage to over $7,000 for some marketplace bronze plans. Once the deductible is met, the insurance plan starts sharing costs.

Copayments are fixed dollar amounts paid for specific healthcare services, such as a doctor’s visit or a prescription. These are paid at the time of service and do not count towards meeting the deductible. Coinsurance is a percentage of the costs an individual is responsible for after the deductible is met. A common coinsurance split is 80/20, meaning the insurer pays 80% and the patient pays 20% of the approved costs.

An out-of-pocket maximum is the highest amount an individual pays for covered medical expenses in a given year. This limit includes amounts paid towards deductibles, copayments, and coinsurance. Once this maximum is reached, the insurance plan covers 100% of additional covered medical expenses for the remainder of the policy year. For instance, in 2024, the out-of-pocket maximum for an individual marketplace plan could be up to $9,450.

Choosing healthcare providers not part of an insurance plan’s network can significantly increase costs. Out-of-network services result in higher deductibles and coinsurance percentages, as the negotiated rates with the insurer do not apply. Prior authorization is a process where the insurer pre-approves certain medical treatments or tests before they are performed. Although some insurers have eased prior authorization requirements for cataract surgery, confirming approval is important to avoid unexpected denials or delays in coverage.