Medicare & Cataract Surgery Coverage
Cataracts, a clouding of the eyes natural lens, is a condition of aging so common that half of all Americans are affected by age 80. Fortunately, Medicare helps pay for certain medically necessary eye services like cataract surgery. In fact, eighty percent of cataract surgery in the US is performed on Medicare beneficiaries! Heres what else you need to know about Medicare coverage of cataract surgery.
Does Medicare Cover Glasses
Normally, Medicare does not cover routine vision correction, but Medicare does cover eyeglasses, contact lenses, and intraocular lenses following surgery to treat cataracts.
If you require eyeglasses, Medicare Part B only provides coverage for standard frames. For more expensive frames, youll pay the difference over the amount approved by Medicare. Ask your doctor what frames are covered by Medicare.
Make sure your supplier is enrolled in Medicare and has a Medicare supplier number because Medicare wont pay your claim if your supplier doesnt have a Medicare supplier number.
Youll pay 20% of the amount approved by Medicare , plus your Medicare deductible. Remember to tell your doctor to send the bill for your eyeglasses or contact lenses to Medicare.
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The Details Regarding The Cost Of Cataract Surgery
If only there were a simple answer to this question. Every medical and surgical procedure is associated with a CPT code . The CPT code for cataract surgery is 66984, although 66982 is also a cataract surgery code used when the cataract surgery is complex, which can happen for any number of reasons.
When it comes to the cost of any medical or surgical procedure, every doctor, medical office, and hospital comes up with a price for any given CPT code. Think of this as the sticker price. Keep in mind that hardly anyone ever pays the sticker price. When doctors decide to be in-network with any insurance company, they accept and/or negotiate rates for various CPT codes. Also keep in mind that many surgery CPT codes and their associated charges include post-operative visits in that one cost.
As an example, the surgeon fee sticker price for cataract surgery may be $1500, but the surgeon has agreed to accept, say, $900 from Blue Cross Blue Shield . In that case, for a patient with BCBS, the surgeon fee is $900. Now whether it is BCBS or the patient that pays that $900 depends on the actual BCBS plan and any relevant deductibles, co-insurance, and co-payments. In my experience, the average patient would usually have to pay about $150 of this $900 based on the most common plans, with BCBS paying the rest.
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How Much Does Cataract Surgery Cost
In 2020, the average cost of cataract surgery was $2578 per-eye at an outpatient hospital facility, with the cost at a standalone surgery center being about $1000 less. Most of the cost is the facility fee , with the doctors fee being the same at $557.
Depending on the particular needs of your case and its complexity, your costs may be higher or lower than this, though Medicare will usually cover 80% of it. For example, for an outpatient treatment, Medicare would cover $2063 of the cost, leaving a co-payment of $515 as your out-of-pocket fee.
Your Surgeons Credentials And Level Of Experience
Cataract surgery is performed by eye doctors who are likely to be more experienced and more expensive because of their specialized training. Ophthalmologists who frequently perform this specialized surgical procedure may charge more than those with less experience, or they may be able to offer lower prices because they have developed efficiencies.
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Treating Cataracts With Surgery
Doctors will often recommend surgery to treat cataracts. If you have cataracts in both eyes, the surgery is usually performed on one eye at a time. However, the correction of cataracts in one eye may be enough to improve your vision, and your doctor and you may decide to opt to cancel the surgery on your second eye.
Cataracts surgery is usually done on an outpatient basis, and it essentially involves replacing the natural lens in the affected eye with an artificial lens. The surgery has become fairly common: many people have cataracts removed every year, and most surgeries are successful and free of complications. But you should always discuss the risks of such surgeries with your medical provider.
Cataract surgery is extremely popular because it usually provides a lasting solution to a common problem. The surgery removes the entire lens and replaces it with an artificial lens that cannot develop a new cataract.
Your vision will likely continue to improve in the weeks following your cataracts surgery. In some cases, people still require reading glasses even after the cataracts are removed, which will be determined by your eye doctor.
In certain cases, even if you have cataracts, you may not need surgery at all. Ask your doctor about other options to treat cataracts. Medicare may cover non-surgical medical treatments for cataracts depending on necessity and type.
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Does Medicare Cover Other Costs That Come With Cataract Surgery
Original Medicare doesnt cover eyeglasses or contact lenses in most circumstances. But if you need them after cataract surgery, Medicare Part B pays for one pair of eyeglasses with basic frames or one set of contact lenses.
The copay for corrective lenses after each cataract surgery is 20% after you meet the Part B deductible. Youll pay more for fancier frames. Your supplier of corrective lenses must be enrolled in Medicare.
What Medicare Does And Doesnt Cover
Generally, Original Medicare pays for 80 percent of the cost of cataract treatment. This includes:
- Surgery, in which the cataract is removed and an artificial lens is implanted
- Pre- and postoperative ophthalmologist exams
- One pair of corrective eyeglasses and contact lenses
Original Medicare includes Medicare Part A hospital insurance and Medicare Part B medical insurance. The eyeglasses or contacts prescribed after surgery fall under Part B coverage. Though hospital expenses are covered under Part A, you likely wont need a hospital stay for cataract surgery.
If you have a Medicare Advantage plan, your insurance provider should pay for both the cataract surgery and the corrective glasses or contact lenses. Medicare Advantage plans are required to provide the base level of benefits offered through Original Medicare coverage.
Under Original Medicare, you are responsible for the remaining 20 percent of expenses, including any deductibles, copayments, or coinsurance involved with cataract surgery and exams.
If you dont want to pay out-of-pocket, you can enroll in a Medicare Supplement plan, which handles extra costs not covered by Original Medicare.
Presurgery eye drops may be covered by Medicare Part B. Any other medications prescribed to you postsurgery, including eye drops, may be covered by a Medicare Part D prescription plan.
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Financing Your Cataract Surgery
Typically, cataract surgery is covered by insurance and Medicare. However, in the event that your procedure is not fully covered, or if you elect to choose an upgraded lens option as part of your treatment plan, NVISION® offers financing options to ensure that you are not inhibited by cost. Read on to learn more about CareCredit® and see how cataract surgery can be affordable.
Cataract Surgery: What Are Cataracts
Cataracts are a clouding in your eyes natural lenses. Once cataracts form, the lens becomes increasingly opaque as cataracts interfere with light getting through to your retina. You can have cataracts in one eye or both.
Outpatient cataract surgery is typically covered under Medicare Part B benefits, while inpatient surgery is usually covered under Medicare Part A. You may have greater coverage and lower out-of-pocket costs if you have a Medicare Advantage or Medigap plan.
The actual cause of cataracts is unknown. However, the breakdown of lens proteins and other chemical changes associated with aging are contributing factors to cataracts.
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Does Private Insurance Cover Cataract Surgery
Most health insurance providers consider cataract surgery to be medically necessary, therefore they will cover at least a portion of the costs associated with standard cataract surgery. Cigna, Aetna, United Healthcare, and other smaller insurance providers will all cover a significant part of your cataract surgery. Speak directly with your healthcare provider to find out what is covered by your plan.
What Coverage Exclusions Might Apply
Medicare covers traditional and laser cataract surgery, but has not yet begun paying for New Technology Intraocular Lenses . For example, some toric lenses, designed to correct astigmatism, may not be fully covered. Discuss with your eye doctor whether it makes sense for you to pay more for the potentially greater improvement in vision.
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What Is The Average Cost Of Cataract Surgery
Cataract surgery can range from $3,800 to $7,000 per eye without a health insurance plan. For standard cataract surgery, the average cost is $3,700.
However, the average cost of astigmatism-correcting surgery is $5,000, and presbyopia-correcting is about $7,000.
What does Medicare pay toward cataract surgery? It depends on the Medicare plan you are enrolled in. If you are only enrolled in Original Medicare, you will need to pay a 20% coinsurance and your Medicare Part B deductible, which is $185 in 2019.
You may be able to get even more coverage through a Medicare Supplement plan or Medicare Advantage plan. Additionally, because cataracts cloud the eye lens, eye surgery is classified as a medical condition.
This means that Medicaid could also pay some of your cataract surgery costs.
Cataract Surgery Combined With Other Ocular Surgery
- When patients have other ocular diseases coexistent with their cataracts, there is a role for cataract surgery combined with other types of surgery. For example:
- Patients with glaucoma and cataracts may sometimes have a glaucoma procedure combined with their cataract surgery
- Cataract surgery may be combined with corneal transplantation in patients with corneal disease
- Combined cataract surgery and vitrectomy can be used in cases where the cataract interferes with the surgical treatment of posterior segment pathology1
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Cataract Treatment Begins With A Consultation
Since costs vary significantly, you should start by booking a consultation with an ophthalmologist. He or she can give you an estimate based on your needs and treatment options.
If you have a Medicare Advantage plan, call your insurance provider to confirm how it covers the type of treatment youre looking for and about any coverage rules, such as prior authorization or a network. If you have a Medigap policy, your coverage will pair with Medicare automatically.
Although Medicare and cataract surgery coverage may seem complicated, millions of seniors undergo successful procedures every year. The procedure itself is simple, low-risk, and can permanently improve your vision.
Cataract surgery doesnt have to be expensive either. There are a few ways to lower your out-of-pocket costs. These include choosing standard surgery, buying a Medicare Supplement plan, or in some cases, switching to Medicare Advantage.
As you start your journey toward better vision, ask questions. Your doctor and insurance provider can help you decide which options meet your needs and budget.
Does Medicare Pay For Intraocular Lens
Cataract surgery involving intraocular lens implants, which are small clear disks that help your eyes focus, is covered by Medicare. The Medicare program does not cover more advanced implants, even though it covers basic lens implants. In addition to the surgery, Medicare will cover a pair of glasses or contact lenses after the procedure.
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Does Original Medicare Cover Cataract Surgery
Yes, Medicare Part B generally covers surgery to remove cataracts. Cataract surgery involves replacing the affected eye lens with an artificial one, and Medicare Part Bs benefits usually cover the costs associated with this surgery.
Medicare Part B covers ophthalmologist and facility fees, provided that the amount has been approved by Medicare. You typically pay a 20% coinsurance fee for the surgery and anesthesia, if necessary, as well as your Part B deductible . Medicare also covers the pre-surgery exam where you will meet to discuss your cataracts and any necessary post-surgery follow-up care.
Medicare Part B generally covers one pair of eyeglasses or contact lenses if needed after the surgery again, you pay 20% of the Medicare-approved cost. The glasses or lenses must come from a Medicare-approved provider.
A Medicare Advantage plan also covers cataract surgery and related expenses as explained above, because these plans include all Medicare Part A and Part B benefits . Available from private insurance companies that contract with Medicare, Medicare Advantage plans often include additional benefits, such as prescription drug coverage.
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Original Medicare Coverage For Cataract Surgery
Cataract surgery is covered by Medicare Part B. This part of Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage…. is for outpatient services. Original Medicare covers:Medicare.gov, Eyeglasses & contact lenses, Accessed November 18, 2021
- Cataract Removal
- Lens Implants
- Pair of Eyeglasses or Contact Lenses
Several factors are considered when Medicare reviews the claimA request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered…. for cataract surgery.
Despite the coverage from Medicare or medical insurance, many patients can still be responsible for out-of-pocket costs in the way of physician/surgeon fees, copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service…., and deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share….. There may also be out-of-pocket expenses if you decide on advanced implants instead of the standard mono-focal ones.
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Undergoing Cataract Surgery With Part B
Part B covers your outpatient care and is most likely what you will use to cover your cataract surgery. Under Part B, only 80% of the cost of your cataract surgery will be covered. You will be responsible for the remaining 20%. Part B will cover your lens implant, removal, and the prescription glasses or contact lenses covered for the procedure. The Part B deductible is quite low at $198.
Does Medicare Pay For Cataract Surgery
The majority of cataract patients in the U.S. are over 65 years old and qualify for Medicare coverage for cataract surgery. Usually, Medicare covers more than 80% of the cost of cataract surgery, particularly if you get standard monofocal IOLs.
Advanced technologies such as the femtosecond laser, ORA, and premium lens implants are not covered by Medicare, the VA, or any other health insurance plans, says Dr. Emilio Justo, an ophthalmologist in Sun City West, Arizona. They should be considered as important upgrades on an individual basis. Laser cataract surgery is usually performed when a premium presbyopia-correcting or astigmatism-correcting IOL is implanted.
While Medicare doesnt usually cover glasses or contact lenses, Medicare Part B medical insurance helps pay the additional costs of corrective lenses, if you have cataract surgery to implant an intraocular lens.
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Is Cataract Surgery Worth The Money
Of 21 RealSelf members reviewed their procedure, 83% say that cataract surgery was Worth It.
About 95% of people who have this safe, painless, and effective surgery have improved vision afterward. Better still, their enhanced vision typically lasts a lifetime because the new artificial lenses cannot form cataracts.
While waiting to have cataract surgery wont damage your eyes or make the surgery more difficult, having it will probably significantly improve your eyesight and quality of life. I tell patients that the time for cataract surgery is when you cannot see to do what you want to do, says Dr. Mark Golden, an ophthalmologist in Chicago.
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The Technology Used During Surgery
Traditional cataract surgery involves making a very small incision on the cornea to remove the cataract. A laser then breaks up the cataract so it can be suctioned out and removed.
Laser cataract surgery, which is typically more expensive, uses a laser to create the initial incision instead, reducing certain risks and improving the visual outcome of cataract surgery.
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How Much Does Medicare Pay For Lenses After Cataract Surgery
Cataract surgery is generally covered by Medicare Advantage plans. In spite of the fact that Medicare does not generally cover eyeglasses and contact lenses, it does provide coverage for one set following cataract surgery. A beneficiary must pay Medicare-approved amounts in proportion to 20% of the amount.