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Does Medicare Part A Cover Cataract Surgery

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What Does Medicare Cataract Surgery Coverage Include

Does Medicare Cover Cataract Surgery?

Original Medicare covers an intraocular lens replacement, facility and doctor services during the surgery, and one pair of prosthetic eyeglasses or contact lenses. It also covers postoperative complications that are addressed in the office.

A basic cataract procedure involves the surgeon using a blade to remove the lens. The surgeon then replaces it with a monofocal lens that replaces the cloudy lens but doesnt enhance your vision. Subsequently, you might still require contacts or glasses after cataract surgery.

However, it is possible to upgrade your surgery by paying the additional costs out of your pocket. For instance, you can get bladeless surgery and multifocal lenses, so you dont require glasses or contacts. You will pay the remaining balance after Medicare pays for the standard procedure. Before moving forward, talk to the provider to find out exactly how much the out-of-pocket costs will be.

What Is A Cataract

A cataract is a cloudy area in the lens of the eye that can make vision blurry. Most cataracts develop as people age but cataracts can also occur from an eye injury or previous eye surgery.2

Cataracts are common as well. More than 50% of Americans aged 80 or older have cataracts or have had cataract surgery to get rid of them.3 Cataract surgery corrects vision problems caused by cataracts and is 1 of the most common, safe, and effective types of surgery done in the United States.4

Medicare And Lenses After Cataract Removal

Normally, Medicare will not cover the cost of glasses or contacts. However, after cataracts have been removed, Medicare will often cover eyeglasses, contact lenses, and intraocular lenses required to restore vision following the surgery.

Patients will need to pay 20 percent of the Medicare-approved amount plus their Medicare deductible.

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When Does Medicare Cover Cataract Surgery

If the cataract surgery is performed as an outpatient procedure by a Medicare-approved doctor, it may be covered under Medicare Part B .

For medically necessary vision services that are covered under Medicare Part B, you typically pay 20 percent of the Medicare approved amount and Medicare pays 80 percent. Keep in mind that you must meet your Part B deductible before Medicare will begin paying its share.

Before your surgery, speak with your doctor about how much you may have to pay out of pocket for the procedure and for aftercare.

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What Lenses Does Medicare Cover For Cataract Surgery

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What Are Risks Of Cataract Surgery

As with any surgery, there are certain risks, including loss of vision, double vision, infection, or inflammation. However, according to the National Eye Institute, cataract surgery remains one of the safest and most common ways to treat cataracts, and 90% of those who get the surgical procedure have improved vision after.

Talk to your doctor about the risks of cataract surgery and whether this might be the right course of treatment for you.

What Is The Best Medicare Plan For Cataract Surgery

Several Medicare Advantage plans cover all costs for cataract surgery, though youll need to find a physician, hospital or surgery center that is contracted with your specific Advantage plan. To keep costs down, you may also want to seek an Advantage plan that has low copays and includes vision insurance.

Most doctors and hospitals are contracted with Original Medicare, though not all are contracted with Medicare Advantage. Youll also need to pay for 20% of your procedures total cost.

You might consider a Medicare Supplement plan to bolster your basic Part B coverage. Plan G, for example, covers all cataract surgery costs, save for your Part B deductible and Medigap premium payments.

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Can I Find Out How Much Medicare Will Cover Before I Choose To Have Surgery

Yes. The Centers for Medicare & Medicaid Services offer a searchable database on outpatient procedure costs. That data tool can tell you the national average cost of cataract surgery and the amounts Medicare will pay. Keep in mind, though, that these prices are for people who:

  • Have original Medicare

  • Have already met their Part B deductible

  • Do not have Medigap policies

After you reach your deductible, Part B pays 80% of the Medicare-approved amount. Your coinsurance share is 20%.

To be covered, your cataract condition must meet Medicares rules of medical necessity. CMS considers these factors in making its decision:

  • How severe is your condition? For example, a foggy lens without other symptoms may not qualify.

  • Do you also have other eye diseases?

  • How much is the cataract limiting your activity?

  • Does your documented medical history confirm the necessity?

Some Medicare Advantage Plans Cover Routine Vision Care

Does Medicare Cover Cataract Surgery

Neither Medicare Part A or Medicare Part B cover routine vision care or eye exams.

Medicare Part B covers some diagnostic tests and treatments associated with vision care:

  • Tests and treatment for macular degeneration, including certain injected drugs
  • One glaucoma test every 12 months for people who are at high risk of developing glaucoma
  • One yearly exam for diabetic retinopathy

Medicare Advantage plans are an alternative to Original Medicare that provide the same coverage as Medicare Part A and Part B combined in one plan.

Some Medicare Advantage plans may offer vision care, as well as dental care and prescription drug coverage.

If you wear glasses or have an eye condition that requires frequent visits to the optometrist, you may want to consider enrolling in a Medicare Advantage plan that includes vision coverage.

Find Medicare Advantage plans that cover cataract surgery

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About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.

Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

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Additional Questions To Ask Your Doctor Before Cataract Surgery

Elizabeth Chiang, M.D., an ophthalmologist and oculoplastic surgeon based in Brecksville, Ohio, suggests patients ask their eye doctor the following questions during a cataract surgery consultation:

  • Am I at a higher risk than others for any complications?
  • WIll you be performing my surgery? If not, who will be operating on me?
  • Will you see me for my post-op visits, or will I be seeing someone else?
  • Do you do dropless cataract surgery, or will I have to use eye drops after surgery?
  • Will I wear an eye patch after surgery? If so, for how long?

If you have glaucoma, ask if any other procedures will be done during your cataract surgery to treat it, adds Dr. Chiang.

Medicare.gov suggests asking your eye doctor the questions below before any procedure, including cataract surgery:

  • Which hospitals or surgical centers do you work with?
  • Which facility is best for me, based on my health status?
  • What happens if I have a medical emergency while Im at an ambulatory surgical center, which is not a hospital?
  • If I have a Medigap plan, do I need to use a certain hospital or surgical center?
  • Does my Medigap plan require me to get a pre-authorization or referral before having cataract surgery?

When Should I See A Doctor

Cataracts arent always noticeable in their early stages, which is why its best to schedule regular visits with your eye doctor for early detection.

But, if you do experience any of the following symptoms, its time to visit your doctor:

  • Indistinct differences between colors

So, does Medicare pay for cataract surgery? Yes, once your deductible and co-payment are met, Medicare can cover the rest and keep your treatment affordable for you.

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How Do I Estimate My Cost For Cataract Surgery

Its easy to determine your costs for cataract surgery ifyou have a Medicare Supplement plan. You can do so by performing the followingsteps:

  • Review your plan details, looking specificallyfor coverage for deductibles, coinsurance, and excess charges
  • Ensure that your doctor and all related careproviders accept Medicare
  • Contact your Part D prescription provider todetermine the costs of any antibiotics or painkillers that youll be prescribed

If you have Medicare alone, youll need to:

  • Ask for a breakdown of whats charged for eachstep of the procedure
  • Find out which parts of the procedure arecovered 100 percent and subtract that amount from the total cost of theoperation
  • Plan on paying 20 percent of the amount that isnot completely covered
  • Determine your prescription medication costs
  • Determine copayment in advance for after surgerycare and doctor follow-up

If you have a Medicare Advantage plan, youll need tocontact your carrier directly. These plans can vary widely, so ask what stepsyou need to take to determine your costs.

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What Are The Costs Of Cataract Surgery

For people with original Medicare, the national average price of cataract surgery at an ambulatory surgical center is $1,606. The out-of-pocket cost can be as little as $320.

That said, several factors can affect your personal medical bill. These include:

  • Choice of facility: Surgery at an ambulatory surgical center typically costs hundreds of dollars less than at a hospital outpatient facility.

  • Type of surgery: There are two commonly used techniques for cataract surgery. Phacoemulsification uses a small incision extracapsular cataract extraction uses a larger one. A Medicare beneficiarys average ASC price is $361 for ECCE or $369 for phaco.

  • Type of artificial lens: Medicare only covers one type of IOL: the standard monofocal lens, which provides clear vision at one distance. But there are different types of IOLs. If you choose an advanced multifocal lens , it could cost you thousands of dollars out of pocket.

  • Potential post-surgery expenses: These can sometimes be costly. For instance, retinal detachment is a common complication. For surgery to repair it, a Medicare patients out-of-pocket cost can range from hundreds of dollars to more than $1,000. The total cost depends on the type of procedure.

Medigap And Cataract Surgery

Medigap works by filling the gaps of Original Medicare and covering additional costs. Medigap generally doesnt cover long-term care, vision, or dental, as well as hearing aids and eyeglasses. Medigap can cover some remaining costs of cataract surgery, however, such as Part A and Part B deductibles and coinsurance.

FYI: To learn more about Medigap, read my rundown of the best Medigap policies.

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Medicare Part D Coverage For Cataract Surgery

Medicare Part D prescription drug coverage can help you pay for the prescription drugs you will need following cataract surgery.

Types of Drugs Typically Prescribed Before or After Cataract Surgery

Antibiotics
Antibiotics are often prescribed to prevent endophthalmitis, a rare but serious complication that can follow cataract surgery along with other bacterial infections. They are prescribed for a few days before surgery until a week or two after.
Corticosteroids
These steroids can reduce inflammation caused by the trauma of surgery and the release of lens proteins that can result in a painful, red eye. You usually take these medications for a few weeks following surgery.
Nonsteroidal Anti-Inflammatory Drugs
These are anti-inflammatory drugs that work differently and can be used in conjunction with corticosteroids. Many are over-the-counter medications such as aspirin, Advil and Aleve. Other drugs in the class, such as Celebrex, may require a prescription.

If you have Original Medicare, youll have to purchase a separate Part D prescription drug plan, but these plans are often included in a Medicare Advantage plan. You should check if a Part D plan is included before purchasing a Medicare Advantage plan.

Some medications related to your immediate surgery may be covered by Medicare Part B, but only if Medicare considers them to be medical, rather than prescription drug, expenses.

Does Medicare Cover Cataract Surgery

Medicare Explained: Does Medicare Cover Cataract Surgery and Glasses?

Find Cheap Medicare Plans in Your Area

Cataract surgery is covered by Medicare, and how much you’ll pay for the surgery will depend on which type of Medicare plan you have and the plan’s coverage level. For those who have Medicare Part B, the average out-of-pocket cost for cataract surgery ranges from $207 to $783.

One of our top recommendations is to sign up for Medigap Plan G from AARP, which gives you cataract surgery at a $0 copayment, with an average policy costing about $150 per month. You can also get great coverage with the more convenient Medicare Advantage plan from Aetna, which has cheap monthly rates and includes vision insurance.

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Medicare Requirements For Cataract Surgery

Your vision must be 20/40 or worse to qualify for surgery. Your doctor will need to document that your vision is at this level or lower.

You also need to have difficulty completing daily living activities like reading, sewing, watching television, or driving.

Its important to remember that the cloudiness in your eye is not directly correlated to the severeness of your cataracts. If you are unsure of your vision level or whether or not you qualify, visit your eye doctor.

Which Medicare Parts Cover Cataract Surgery

Medicare Part B pays for the fees associated with cataract surgery. However, you must pay your Medicare Part B coinsurance and the deductible. The deductible usually goes up slightly from one year to the next.

Original Medicare covers 80% of the cost of cataract surgery, while patients pay the remaining 20% after meeting their Part B deductible.

Many people can reduce out-of-pocket costs while improving coverage by choosing the Medicare Advantage Program. The program allows for additional private plans on the insurance marketplace and provides the same benefits as Medicare, although most include extras. For example, you might be eligible for different lenses and types of cataract surgery under the Medicare Advantage Program. Reading the fine print to determine what is covered and your out-of-pocket costs is essential.

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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 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.

Cataract Surgery Cost And Coverage With Medicare

Cataract When To Have Surgery

Medicare covers both types of cataract surgery equally. Your eye doctor will help you determine which is better for you during an eye exam.

The different plans of Medicare come into play at various points of your cataract surgery journey and provide coverage for different expenses, while working together to help you walk away from your procedure with the lowest cost possible.

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Things To Discuss With Your Doctor Before Cataract Surgery

Before your cataract surgery, you should ask your doctor as many questions as youd like, including:

  • Will I experience complications?
  • Who will be performing my surgery?
  • Who will I be seeing for my post-op visits?
  • Will I have to use eye drops after surgery?
  • Will I have to wear an eye patch after surgery, and for how long?

Additionally, it would be best if you discussed some questions with your eye doctor before any procedure, including:

  • Which hospitals or surgical centers do you work with?
  • Which facility is best for me?
  • What should I do if I have a medical emergency at a surgical center?
  • Does Medigap require me to get a referral before cataract surgery?

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