Medicare and Cataract Surgery: What Does Medicare Pay?

• Cataracts are an incredibly common eye condition in older people. Cataracts can be removed surgically via a variety of surgical methods.

• Without insurance, cataract surgery costs can be quite expensive. 

• Original Medicare pays for most cataract surgery costs under Medicare Part B. A Medicare Advantage plan will also cover cataract surgery.

• A Medigap plan may help cover additional health care costs, such as copayments, premiums, and deductibles, meaning lower health care costs overall.

Cataracts are a common condition among older populations. In fact, according to the National Eye Institute, over half of all Americans age 80 and older either have cataracts or have had surgery to remove cataracts. 

Because cataracts are so prevalent in older populations, many Medicare beneficiaries may be affected by this eye condition at some point. But does Medicare cover cataract surgery since the federal Medicare program typically excludes vision care? This article will explain everything beneficiaries need to know about Medicare and cataract surgery. 

A cataract is a clouding of the lens in the eye. This condition is a very common part of the aging process. While cataracts often do not have any early warning signs, later symptoms include blurred vision, muted color perception, light sensitivity, difficulty seeing at night, and double vision. 

How Are Cataracts Diagnosed? 

Cataracts are diagnosed via a dilated eye exam. If cataracts are present, cataract surgery can remove them. The exact type of cataract surgery will be decided on by the patient’s medical provider.

Cataract surgery is a procedure in which a doctor will remove the cloudy lens from an individual’s eye and replace it with an artificial lens. This is referred to as an intraocular lens (IOL). The surgery usually lasts only an hour and is pain-free.

Cataract surgery is recommended for those with cataracts that impair everyday activities such as driving, reading, or watching television.

There are three main types of cataract surgery include phacoemulsification, extracapsular, and laser.

Phacoemulsification Cataract Surgery

The most common cataract surgery, phacoemulsification breaks up the cloudy lens prior to its removal and then replaces that lens with an IOL.

Extracapsular Cataract Surgery

This type of cataract surgery removes the cloudy lens in one piece, as opposed to breaking it up first, followed by the implantation of the IOL.

Laser Cataract Surgery

A laser cataract surgery essentially uses a laser as opposed to a knife to make the incision in the eye to remove the cloudy lens. From there, the remaining of the surgery is similar to that of phacoemulsification. Laser surgery is often quicker and lessens recovery time.

Note: Learn more about cataract surgery at this resource.

Benefits

There are various benefits of cataract surgery. These include: 

• Better vision

• Improved quality of life 

• Safer night driving

Complications

Complications from cataract surgery are rare but can include: 

• Inflammation

• Infection

• Bleeding

• Swelling

• Drooping eyelid

• Dislocation of artificial lens

• Retinal detachment

• Glaucoma

• Secondary cataract

• Loss of vision

Without health insurance, the average cost for cataract surgeries can range from $3000 to $5000 per eye. Advanced types of cataract surgery, such as premium cataract surgery, can cost even more per eye. 

There are a variety of factors that will contribute to cataract surgery costs, beyond the procedure itself. These include IOL lens type, whether a laser is used, whether the procedure is done inpatient or outpatient, what state the Medicare beneficiary lives in, etc.

It’s important to note that cataract surgery can be performed in multiple medical locations including an ambulatory surgical center or a hospital outpatient department and that the prices of the procedure differ depending on location. If it is performed in an ambulatory surgical center, the cost will be cheaper than at a hospital outpatient department.

An Original Medicare covers cataract surgery. The amount covered will vary based on the specific Medicare plan, however. As a reminder, Original Medicare consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). These Medicare Parts do not include prescription drug coverage. Original Medicare beneficiaries would have to also enroll in a Medicare Part D prescription drug plan in order to get any prescription drugs covered. 

In short, Medicare covers standard cataract surgery including:

• Cataract removal

• Standard intraocular lens implants (toric lenses cost extra)

• One pair of prescription eyeglasses or a set of contact lenses post-op

Medicare Part B covers cataract surgery so long as it is performed using traditional surgical techniques (i.e. phacoemulsification or extracapsular). Cataract surgeries are usually performed on an outpatient basis, meaning a hospital stay is usually not necessary. 

While Medicare pays most of the costs for standard cataract surgery that implants monofocal lenses, Medicare doesn’t cover additional costs, such as the use of premium IOLs or laser cataract surgery.

Medicare will pay around 80% of the Medicare-approved amount of the surgical procedure. The Medicare-approved amount refers to the total cost of a doctor or supplier is paid. This means patients are expected to pay the remaining 20%.

Note: Learn more about Medicare cataract surgery costs at this resource.

How Does Medicare Coverage Work for Prescription Lenses After Cataract Surgery?

Original Medicare doesn’t cover vision care in most cases. This includes prescription eyeglasses or contact lenses, routine eye exams, etc. That said, Medicare Part B will cover corrective lenses (i.e. one pair of prescription glasses with standard frames or one set of contact lenses) following cataract surgery.

Medicare Advantage plans, also known as Medicare Part C or MA plans, are Medicare plans offered through private insurance companies that are Medicare-approved. Medicare Advantage plans bundle Medicare Parts A and B. As well, these plans may include additional benefits such as vision, hearing, and dental. Medicare Advantage plans also often include Medicare Part D. Medicare Advantage beneficiaries should always check with their insurance company to confirm extra benefits.

Because Medicare Advantage plans combine Medicare Parts A and B, Medicare Advantage plans will most likely cover cataract surgery since it automatically includes Medicare Part A and Medicare Part B benefits.

Medigap or MedSupp plans are supplemental Medicare plans. Like MA plans, these intend to ​“fill in the gaps” of Original Medicare coverage. A Medigap policy helps pay extra costs, such as Medicare Part B’s annual deductible, which would help with cataract surgery coverage since the Part B deducible applies.

Dual Eligibles plans incorporate Medicaid services as a supplemental insurance plan to Original Medicare. Coverage under this plan varies and it’s improtant to reach out to a licensed insurance provider to discuss the breakdown of your Dual Eligbles plan when scoping out the costs of cataract surgery.