Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Does Medicare Cover Cataract Surgery?
According to the National Eye Institute, more than half of all Americans who are age 80 or older are either living with cataracts or have had surgery to get rid of them.
Cataract surgery to replace a blurry natural eye lens with a clear artificial lens called an intraocular lens (“inside the eye”) is one of the most common procedures in the United States.
Medicare covers standard cataract surgery if it’s done using traditional surgical techniques or using lasers. The procedure must be deemed medically necessary and is typically covered under Part B (medical insurance) as an outpatient procedure. This coverage is partial and subject to deductibles and copays or coinsurance.
Your total out-of-pocket costs depend on where the operation is done, what type of technology and intraocular lens are used, and which type of Medicare insurance you have.
Which Medicare Plans Offer Cataract Surgery Coverage?
- Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), offers cataract surgery coverage. This procedure most often takes place in an outpatient setting, such as an ambulatory surgery center, or a hospital outpatient department, both of which fall under Part B benefits. Part A coverage would only apply if the surgery is done in a hospital.
- Medicare Supplement Insurance (Medigap) plans help cover the out-of-pocket costs you incur when you access your Original Medicare benefits. For instance, if your cataract surgery takes place in an outpatient setting (which is most common), Part B will pay for 80% of approved Medicare charges after you satisfy your annual deductible. Most Medigap plans will cover the other 20%. You will still be responsible for the Part B annual deductible and your Medigap monthly premium.
- Medicare Advantage (MA) plans, as an alternative to Original Medicare, also cover cataract surgery. MA plans provide the same benefits as Original Medicare does, so if a service is covered under Original Medicare, in this case, cataract surgery, it is also covered under a MA plan.
Both MA plans and Medigap plans are approved by Medicare and are offered by private insurance companies. You cannot have both at the same time.
The differences between having cataract surgery with Original Medicare (with or without a Medigap plan) and a MA plan lie mainly in the out-of-pocket cost structure and your choice of provider. With Original Medicare, you can have cataract surgery from any provider or facility that accepts Medicare. With a MA plan, you can have the surgery through a provider and facility that are in-network with your plan.
With Original Medicare, you are responsible for 20% of the Medicare-approved charges after you satisfy your annual Part B deductible ($203 for 2021). Part B covers 80%.
With a MA plan, you may be responsible for a copay for the healthcare provider who does the surgery, and you will be responsible for a facility copay. As with Original Medicare, you will also be responsible for the annual Part B deductible before your benefits kick in. MA plans will likely require prior authorization for the procedure, but Original Medicare will not.
How Much Will Cataract Surgery Cost Without Supplemental Coverage?
If you have Original Medicare without Medigap, you will be responsible for 20% of the approved Medicare charges for your procedure after you have met your annual Part B deductible.
Assuming that your cataract surgery will be an outpatient procedure, there are a couple of ways you can try to determine your out-of-pocket costs:
- Use Medicare’s tool to look up the price of your procedure. Costs are based on national averages and include facility and doctor fees. Additional costs may apply. For instance, if you have a common and uncomplicated procedure (Code: 66984) at an ambulatory surgical center, you pay $316 after Medicare pays its portion. The facility costs are higher if you have the same procedure at a hospital outpatient department. In that case, the average patient cost is $524. Note: these costs are for one procedure on one eye.This tool can give you a ballpark dollar amount to work with, but the costs in your area and the complexity of your procedure may be very different.
- For a more accurate estimate, contact the billing department of your Medicare provider and ask for a cost rundown based on what type of surgery you will have and which type of facility it will be in. They are trained and experienced in billing Medicare and should be able to provide you with fairly accurate information, barring any unforeseen complications that may happen during your procedure or recovery period.You may want to ask these questions:
- Which facilities do you work with for cataract surgery?
- Which facility and type of procedure are best for me given my health status and medical history?
- Do you accept assignments? (If so, you won’t be charged more than your deductible and coinsurance)
- What if I have a medical emergency during the procedure at a clinic that is not part of the hospital?
- Are there any other potential costs I should be aware of?
If you end up needing to spend time in the hospital as an inpatient, your Part A benefits will kick in. You will be responsible for your deductible, which is $1,484 in 2021. Part B will continue to cover doctor visits during your stay.
You will pay the lowest cost if you choose a provider who accepts Medicare assignment, which means they have agreed to accept the payment amount Medicare approves for the surgery, and they will not bill you for more than your deductible and coinsurance.
Will Medicare Continue Vision Care Coverage After Cataract Surgery?
As part of your surgical services, you will have a follow-up appointment with your doctor after your surgery to make sure there are no complications. If you have complications or vision care needs related to your surgery that are medically necessary, Medicare will cover those services. You will be responsible for coinsurance charges.
After cataract surgery, Medicare Part B will pay for either one pair of eyeglasses with standard frames or one set of contact lenses from a supplier who is enrolled in Medicare. You pay 20% of the Medicare-approved charges. You have probably already met your Part B annual deductible for your cataract surgery.
If you have a Medigap plan, it will cover the Part B 20% coinsurance. Medicare Advantage plans will cover standard frames or one set of contact lenses as defined by Medicare, just like Part B does.
Regardless of which type of Medicare insurance plan you have, you will be responsible for the costs of any upgrades to your post-cataract surgery standard frames such as deluxe frames, tinting, or progressive lenses.
Your doctor may prescribe eye drops and/or antibiotics after cataract surgery. These would be covered by a Medicare drug plan (Part D) or by your Medicare Advantage plan with drug coverage included. Copays and deductibles may apply.
Subsequent vision care that is medically necessary to treat disease or injury to the eye is covered by Medicare. Routine eye exams and corrective lenses are not.