Medicare and Cataracts Explained

Does Medicare pay for cataract surgery?

Good question.

You may know that Medicare does not provide vision benefits. That means if you have everyday needs for glasses or contacts to see clearly, you will likely pay out-of-pocket for those vision items along with annual eye exams. But, Medicare does provide some levels of coverage for beneficiaries with much more severe eye health issues such as cataracts.

Is cataract surgery covered by Medicare?

Yes!

Cataracts are a treatable condition that can cause blurry or limited vision. Medicare considers cataracts to be a more serious health problem because they can impact your sight in a way that is not repairable through contacts or glasses — instead, cataracts are only treatable through surgery. If a doctor determines that cataract surgery is medically necessary to ensure your sight and health, Medicare will step in to provide coverage. While Medicare does not cover more common eye problems such as nearsightedness or farsightedness, it will help you with the cost of repairing cataracts and offer limited coverage for corrective eye wear you need during recovery.

Cataract Surgery Coverage for Medicare Beneficiaries

Cataract surgery can be pricey — often ranging up to $3,500 per eye. But because Medicare considers it a medically necessary treatment, you will not have to shoulder the cost alone.

Cataract surgery works to repair the opaque, hazy portions of your eyesight by replacing your eye’s lens with a new, artificial one — called an inocular lens — that allows you to see clearly. Medicare will not only pay for the procedure, but also for the artificial lens you receive during the surgery. But beware: Medicare will not cover specialized or “premium” lenses. Most inocular lenses offer near or distance vision, but not both, which explains why many people with cataracts still wear glasses for daily vision. Newer inocular lenses can also offer benefits for astigmatism or accommodate both near and distance sight. If you choose a newer-style specialized lens, Medicare will not cover the cost though it will still pay for your cataract surgery.

Medicare will also help cover the expense of appointments related to your cataract care. This includes meeting with doctors or surgeons prior to your operation at pre-surgery exams to discuss what treatments will be like and answer any questions you have. During your recovery, Medicare benefits will help with the cost of follow-up exams and any treatments you may need. If you require prescription medications that have to be administered outside of a hospital (at home by yourself), having Medicare Part D prescription drug coverage can ensure you pay less to receive them.

There are some scenarios where doctors may attempt to repair other eye injuries or conditions during your cataract surgery. If this is the case, Medicare will only cover your cataract surgery unless a doctor can show that the additional treatment is medically necessary, too.  Still, if you consider having multiple repairs at one time, be sure to contact Medicare or your doctor’s office before entering the operating room to ensure you are not stuck with a large bill during recovery. If Medicare decides it will not cover the additional procedure, you will be billed separately from the doctor’s office, outpatient facility or hospital where you receive treatment.

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Corrective Eyewear for Cataracts

Usually, Medicare will not pay for glasses or contacts to help with vision. But in the case of cataracts, which often require corrective eyewear during the recovery process and after, Medicare will provide help. This means that the glasses you need will be covered. Medicare Part B allows you to choose from a selection of “standard” frames to house your new prescription lenses. Just like selecting premium inocular lenses, if you choose more expensive frames, you will have to pay for much of the cost.

Medicare will only help with the purchase cost of eyeglasses related to your cataract surgery, and often only one time. This means that the glasses you receive using Medicare benefits are a one-time deal. Any new glasses you need for prescription changes following your initial pair will not be covered by Medicare benefits, and you will have to pay 100% of the cost unless you have alternative vision insurance (such as a Medicare Advantage plan or private vision insurance plan).

The only exception to the one-pair rule is if you return for additional cataract surgery. In some instances, cataracts can develop in a second eye. Medicare benefits would then restart, allowing you to receive another corrective surgery as well as the eyeglasses you need afterwards.

Estimating Your Costs for Cataract Surgery

In many cases — regardless of surgery or what doctor you see — estimating the expenses of care can be difficult. Part of this mystery is because doctors can determine that you will need additional procedures, treatments or services during the course of your surgery or care. These unexpected treatments can add up. But, speaking with your doctor and hospital or care facility during the course of treatment can help you determine what kind of care is necessary and how much it will cost (along with the amount Medicare is likely to cover).

If you are admitted to a hospital for cataract surgery, your Original Medicare Part A benefits (hospital insurance) will provide coverage for your procedure. Many cataract repairs are completed as outpatient care, which means Original Medicare Part B (medical insurance) will step in to help cover the cost. If your cataracts are repaired at an outpatient facility, you can expect to pay your Medicare Part B deductible and sometimes a copayment. Often times, you will pay about 20% of the Medicare-approved cost, while your benefits pick up the remaining 80%.

What if you have a Medicare Advantage plan?

Medicare Advantage plans must by law offer the same benefits as original Medicare.  Therefor, if you have a Medicare Advantage plan, your cataract surgery will be covered.  Make sure and check your summary of benefits to best understand your associated copays for cataract surgery.

Finding Vision Coverage

After having cataract surgery, you may find that annual vision exams and eyeglasses are recurring and necessary expenses. If you are enrolled in Original Medicare, you will be stuck with the burden of cost. In this case, it might be smart to consider a Medicare Advantage plan that offers vision benefits that you can use towards eye exams, diagnostic testing, screenings and glasses. Since private insurers offer Medicare Advantage plans, you can select from a variety of plans that help with the vision care you need. Not sure where to start looking for a vision plan? Speak with one of PolicyZip’s Medicare Specialists, who are well versed in the options available to you.