Does Medicare cover cataract surgery?
Depending on your specific Medicare coverage, some, if not all, of the costs associated with cataract surgery should be covered, as long as the surgery is deemed “medically necessary." For cataract surgery to be declared “medically necessary,” your visual acuity must be significantly affected.
Medicare is a federal health insurance program that provides medical coverage for people over 65, although younger individuals with disabilities or certain medical conditions are also eligible.
It’s important to ask the right questions about coverage before undergoing a common procedure like cataract surgery, so you know how much your total bill will be. Lucky for you, we’ve found the answers to some preliminary questions about Medicare and cataracts, specifically, what’s covered and what you can expect to pay.
Cataract surgery cost and coverage with Medicare
Medicare covers both types of cataract surgery (phacoemulsification and extracapsular) equally. Your eye doctor will help you determine which is better for you during an eye exam.
The different plans (or parts) of Medicare come into play at various points of your cataract surgery journey and provide coverage for different expenses, while working together to help you walk away from your procedure with the lowest cost possible.
Medicare coverage for cataract surgery
Medicare Part A covers hospital and inpatient costs. It’s rare for a hospital stay to be required after cataract surgery, but in the small chance that you need to be admitted, Medicare Part A would cover this expense.
Medicare Part B takes care of other medical costs, including outpatient procedures. If your cataract surgery is approved for coverage by Medicare Part B, your pre-surgery exam and any post-surgery care will be covered. Ophthalmologist and facility fees are also covered by Medicare Part B.
Medicare Part C, also called Medicare Advantage plans, are purchased through private insurance retailers and offer different levels of coverage, combined with the coverage of Original Medicare (Parts A and B). Depending on which plan you have, a majority of your cataract surgery cost could be covered.
Medicare Part D provides prescription drug coverage. Individuals who require prescription medication before or after cataract surgery can have the cost covered, as long as the prescription falls under Medicare’s list of “approved” medications.
Medigap is a Medicare supplemental plan that works to cover certain approved costs that Original Medicare does not. In some instances, this can include deductibles and copays; however, it’s best to verify what these approved costs are with your healthcare provider.
SEE RELATED: Do seniors on Medicare need vision insurance?
How much does cataract surgery cost?
According to a 2019 market analysis, the cost of cataract surgery without insurance ranges from $3,783 to $6,898 per eye.
There are cost variables when using Medicare coverage, depending on where the procedure is performed and the surgeon who performs it. To give some perspective on how big the cost variable is, Medicare’s online price lookup tool says the range is anywhere from $51 to nearly $800 for the out-of-pocket costs of cataract surgery.
We recommend confirming your particular cost with your cataract surgeon and insurance provider, as these prices do not include physician fees.
Discovering cost and coverage before cataract surgery
Before your pre-surgery eye exam, we recommend writing down some questions you have for your cataract surgeon. The questions can be general, as well as specific to you and your preferences.
This will help you to remember the specific topics to discuss during your consultation and help you decide whether you should shop around for another eye surgeon that fits your requirements.
Questions to ask your eye doctor before cataract surgery
Do they accept Medicare?
What is the Medicare code for the specific procedure you plan to have? (This code allows you to research the procedure cost through Medicare’s online pricing resource.)
Where will the procedure be performed: a surgical center or a hospital? (The procedure location will influence the cost.)
Will this be an inpatient or outpatient surgery?
Will you require any prescription medications before or after the surgery? If so, which ones?
Your eye surgeon should be willing to discuss with you the different options available and the associated costs not covered by Medicare. From this consultation, you can decide what you do and don’t want done during your cataract surgery, based on your priorities and budget.
For example, Medicare Part B covers basic cataract surgery and intraocular lenses (IOLs), but it will not cover the added cost of certain premium IOLs or procedures. However, choosing a premium IOL or an additional procedure, such as limbal relaxing incisions (LRI) to correct astigmatism, may significantly improve satisfaction with your vision after surgery and be worth the added expense.
The pre-surgery exam is an opportunity for you and your cataract surgeon to gain a shared understanding of what’s to be expected during and after your cataract surgery.
And don’t hesitate to ask questions about costs, insurance, etc. If your surgeon is unsure about a particular Medicare question, reach out to a Medicare representative in your area to get an informed answer.
Whatever your questions or concerns prior to your cataract procedure, talk to your eye doctor and don’t be taken by surprise. Knowledge is power and will enable you to be your own advocate when making these significant medical and financial decisions.
Page published on Monday, January 14, 2019