Cataract surgery is an essential procedure for millions of people who rely on it to restore their vision. Cataracts are when a clouding of the eye's natural lens happens and causes blurred vision. It can happen in one or both eyes. Cataract surgery fixes this by removing the cataract and replacing your eye lens with an artificial lens to give you clear vision.
The risk of cataracts increases with every decade of life, starting at 40. By 2050, the number of people with cataracts in the US may double from around 25 million to 50 million.
In fact, it’s the leading cause of vision loss worldwide, particularly among those aged 65 and older. In the US alone, more than half of all people will live with cataracts or undergo cataract surgery by the time they turn 80.
Cataract surgery can significantly improve older people’s quality of life. But without medical cover, the procedure can cost in the region of $4,000 to $8,000 per eye out of pocket. This is a significant cost for many.
Does Medicare cover cataract surgery?
Health insurance, including Medicare coverage, can cover your cataract surgery in certain circumstances. Typically, Medicare covers the surgical removal of the cataract and its replacement with a conventional monofocal intraocular lens. This includes surgeries performed using traditional surgical techniques.
Patients need to meet specific criteria, however. For instance, Medicare usually only provides cover for medically necessary cataract procedures.
What is a medically necessary cataract procedure?
For cataract surgery to be medically necessary, you must meet specific requirements. Here are a few examples of what makes cataract surgery medically necessary:
- The eye's lens could be affected by a progressive disease that threatens your sight or eye health, for instance, phagocytic glaucoma.
- There's a chance that other treatments or procedures might make your cataracts get worse faster.
- There’s a chance your cataracts could cause problems with vitreoretinal surgery (surgery on the back part of the eye).
- If you've had the lens removed from one eye and still have vision distortions that can't be fixed without surgery, cataract surgery may be medically necessary, too.
These are just a few examples where your eye doctor might decide that cataract surgery is medically necessary.
What is covered under Original Medicare?
The procedure that’s covered is typically for basic lenses. If you want premium lens implants, you may be responsible for those costs.
All Medicare plans will usually cover at least some of the cost of your cataract surgery. Original Medicare consists of Medicare Part A and Part B. These government-run insurance plans cover hospital stays, doctor services, and lab tests. Part A covers inpatient procedures. Part B covers outpatient procedures. This includes cataract surgery coverage.
Medicare Part B typically covers 80% of the Medicare-approved amount for the surgery after you meet your annual deductible. In 2023, the annual deductible was $233. This means you will usually be responsible for a certain coinsurance amount, usually 20% of the cost in addition to your deductible, if you only have the Original Medicare plan.
Your Original Medicare plan may cover corrective lenses if needed after you have an intraocular lens (IOL) implant to fix your cataracts. However, other vision care usually won’t be covered. This includes things like prescription glasses, sets of contact lenses, and eye exams.
You’ll need other medical insurance, such as private insurance, to cover these items.
Supplementing Original Medicare with Medigap
Medigap is a Medicare supplement designed to help with out-of-pocket costs, such as cataract surgery. So, for instance, if, as a Medicare beneficiary, your Medicare policy covers 80% of your cataract surgery, a Medigap plan may cover the additional costs you would normally need to pay out-of-pocket.
The supplement insurance plan used to cover your Part B deductible, too, but as a result of legislation passed in 2021, this is no longer the case.
Medicare Part C
While Original Medicare is government-run, Medicare Advantage (Part C), also known as Medicare Part C, is a private alternative that may come with more “perks”. Medicare still regulates it and must include all the coverage you get under Original Medicare, but it may include features like:
- Dental care.
- Vision care, such as eye exams, eye drops, and contact lenses.
- Hearing care.
- Medicare Part D (i.e., the prescription drug supplement).
This separate insurance plan typically bundles Medicare Part A, Part B, and Part D, which includes your drug coverage. You can’t supplement it with Medigap, and you don’t need to.
Your Medicare Advantage plan will cover your cataract surgery. But you may have different copay amounts and need to use an in-network healthcare provider. Depending on your plan, the total cost may work out cheaper than Original Medicare plans in some circumstances. The exact terms will depend on your insurance company.
How much does cataract surgery cost with Medicare?
The cost of cataract surgery varies and is based on several factors, including:
- The type of lens you choose (some premium options will cost more).
- The type of surgery you choose (laser surgeries typically cost more).
- The surgery center; ambulatory surgical centers may cost less, for instance.
- Doctor’s visits pre and post-op, as well as medications.
Depending on your Medicare plan, your insurance might cover anywhere between 80% and the full surgery cost. With the right Medigap supplement plan, you may need to cover the standard deductible.
But, if you opt for premium lenses, for instance, because you have astigmatism and need astigmatism-correcting lenses, you might need to cover the difference.
Depending on your plan, you might also need to pay out of pocket to buy additional eyeglasses or extra sets of contact lenses.
Medicare and cataract surgery: An overview
All Medicare plans will pay towards the cost of your cataract surgery as long as it’s deemed medically necessary. However, the amount that your policy covers will vary depending on your exact plan. There may be ways to make up additional payments via supplemental insurance or other types of private medical insurance.
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