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.
Designing Your Eyecare Treatment Plan
At Poudre Valley Eyecare, our optometrists can help you take control of your eye health by performing a comprehensive eye exam and designing a treatment plan that meets your needs. Our family-run practice offers premier eye care to the Front Range of Colorado, including Fort Collins, Loveland, Wellington, Timnath and Greeley.
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Do Medicare Advantage Plans Pay For Glasses
While Original Medicare coverage of routine vision care is limited, some Medicare Advantage plans may include additional vision benefits. Medicare Advantage plans are required to provide at least the same level of coverage as Medicare Part A and Part B, but many plans also cover additional benefits that go beyond Original Medicare, which may include routine dental or eye care.
Under a Medicare Advantage plan, vision benefits may include:
- Preventive eye exams covered under Original Medicare
- Routine eye exams
- Contact lenses
Keep in mind that the specific benefits may vary, depending on the Medicare Advantage plans available in your service area. For more information, check with the individual health plan youre considering. If youd like help finding a Medicare Advantage plan that includes vision benefits, you can visit Medicare.gov or call Medicare at 1-800-MEDICARE , 24 hours a day, seven days a week (TTY users, call 1-877-486-2048. You can also contact eHealth to speak with a licensed insurance agent about your Medicare plan options.
Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealths Medicare related content is compliant with CMS regulations, you can rest assured youre getting accurate information so you can make the right decisions for your coverage. Read more to learn about our Compliance Program.
Find Plans in your area instantly!
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Does Blue Cross Blue Shield Cover Cataract Surgery
- Blue Cross Blue Shield Medicare Advantage plans cover cataract surgery, as its covered by Original Medicare . Learn about the other vision benefits some BCBS Medicare plans may offer, how much cataract surgery costs with Medicare and more.
Cataract surgery can cost between $3,500 and $7,000 per eye, which should beg the question of whether its covered by insurance.
Blue Cross Blue Shield Medicare Advantage plans typically cover cataract surgery when its considered to be medically necessary treatment. Medicare Advantage plans are required to cover the same benefits that are covered by Original Medicare .
Because cataract surgery is covered by Original Medicare when performed using traditional surgical methods or with the use of lasers, all Medicare Advantage plans, like the ones from Blue Cross Blue Shield, at least cover the same type of surgery. Some plans may cover even more routine vision care costs than Original Medicare, such as prescription glasses, contacts, eye exams and more.
Blue Cross Blue Shield affiliate companies can vary by state, so its best to compare plans online or call to speak with a licensed insurance agent to find the specific plan benefits available where you live.
Learn More About Medicare And Cataract Surgery
A licensed agent with Medicare Plan Finder may be able to find plans in your area that fit your budget and lifestyle needs.
Are you interested in learning about available plans in your area? Fill out this form or give us a call at 1-855-783-1189 to schedule a no-cost, no obligation appointment with a licensed agent.
If You Have A Medicare Advantage Plan
Medicare Advantage plans, insurance plans offered by private insurance companies, combine Part A and Part B benefits. Medicare Advantage plans often cover services that Original Medicare doesnt, including vision care. Depending on your health-care needs, these plans may be the best Medicare option for you.
Cataract surgery is typically covered by Medicare Advantage plans, but how much you have to pay out of pocket is based on your premium, deductible, and coinsurance or copayment amount.
Why Should You Consider Lasik
It’s clear that scheduling surgery means paying at least some of the costs out of pocket. If your budget is tight and money is a concern, you may wonder why you should pay for a surgery like this. Wouldn’t your money be better spent elsewhere?
The fact remains that LASIK is an exceptional solution for astigmatism, and surgery offers you a solid chance of seeing clearly without constant use of glasses or contact lenses.
For example, in a study published in The Open Ophthalmology Journal, researchers found that 90 percent of people who had LASIK due to myopia and myopia with astigmatism had uncorrected vision that was equal to or greater than 20/20. Studies like this demonstrate just how effective this surgery can be in helping people to avoid constant use of contacts or glasses. If that is your goal, this surgery could be the solution for you.
Only you know how much the ability to leave glasses behind is worth to you. Given results like this, you might be willing to move forward with surgery even if your insurance company decides not to pay for that care.
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Medicare Advantage And Cataract Surgery
Medicare Advantage covers cataract surgery. Your private health insurance provider may cover the full cost of cataract surgery on the condition that you pay outpatient surgery copayments or a deductible. Contact your Medicare Advantage plan provider to see which costs are covered and what youll have to pay out of pocket depending on your plan.
To learn more about this type of coverage, read my guide Medicare Advantage vs. Medigap.
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How Does Astigmatism Develop
Health insurance is designed to provide a buffer between medical expenses and your pocketbook. When you are struggling with a sudden health issue, such as a broken leg or a pinched nerve, you can get the care you need without worrying that the cost of that care will plunge you into poverty. When you have a longstanding issue, such as diabetes, insurance helps to ensure that your medical bills will not overwhelm your budget.
On the surface, astigmatism seems like a condition that should be covered by any medical insurance plan, including Medicare.
People with astigmatism have eyes that are irregularly shaped. That irregularity keeps light from focusing on the vision-sensing part of the eye, causing blurriness. The National Eye Institute reports that people with a slight astigmatism may not notice much vision impairment, but those with advanced cases may experience:
- Recurring headaches.
- Low night vision.
These symptoms can be serious, and they can interfere with your ability to tackle common tasks, such as driving. They can also make your life a little less pleasant, as you may be dealing with discomfort much of the time.
The American Optometric Association reports that the cause of astigmatism is unknown. While it can be present at birth, the severity of the condition can also increase or decrease with time.
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What Eye Procedures Are Covered By Medicare
Routine eye care services, such as regular eye exams, are excluded from Medicare coverage. However, Medicare does cover certain eye care services if you have a chronic eye condition, such as cataracts or glaucoma. Medicare covers: Surgical procedures to help repair the function of the eye due to chronic eye conditions.
What Does Medicare Cover For Cataract Surgery
Welcome to our Patient Guide to everything you need to know about Medicare and Cataract Surgery. In this article, well answer common questions such as:
- Does Medicare Cover Cataract Surgery?
- What Does Medicare Cover For Cataract Surgery?
- Does Medicare Pay For Cataract Surgery With Astigmatism Correction?
- Does Medicare Cover Laser Cataract Surgery?
Well answer these questions and more so that youll be prepared before discussing things with your surgeon and their surgical counselors. Lets get started!
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Does Medicare Cover Laser Cataract Surgery
You may be noticing a theme here as we continue discussing modern technology used in cataract surgery.
Just like the technology used to fix astigmatism and presbyopia, laser cataract surgery is not covered by medical insurance.
Laser cataract systems are guided by complex computer and imaging systems. The first step of a laser cataract procedure is taking high-resolution images of the eye. After obtaining these images, computer software identifies the structures and landmarks for where laser treatment will be applied. Under the guidance of these computer systems, the laser is then applied, performing steps of the procedure with a precision and consistency that the human hand cant match. It is common to use laser cataract systems to correct astigmatism as well.
Medical insurance does not consider the advanced imaging that is a necessary part of the laser procedure to be covered, or any associated astigmatism management or presbyopia management.
Patients who are interested in laser cataract surgery should expect to pay an out-of-pocket fee for laser cataract surgery.
What Is The Vivity Lens And What Are The Potential Benefits Of This Lens
The Vivity lens is a new artificial lens available for patients having cataract surgery. Just like there are different models and manufacturers of cars and refrigerators, there are different models and manufacturers of Intraocular lenses. The Vivity IOL is designed to give your eye a better range of focus compared to a standard monofocal IOL that is only focused at a single distance. The Vivity lens is considered an Extended Depth of Focus lens. The benefit of an EDOF lens is a better range of focus which will help you to see more things without glasses. As compared with a multifocal IOL the Vivity lens will have less negative side effects such as glare and halos around lights at night. The Vivity lens may not focus as close as the Panoptix lens so you may still need glasses for some near tasks such as reading small print. The Vivity lens is considered a high technology IOL so there is an extra cost for this lens that your medical insurance will not cover.
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Does Medicare Cover Glasses Or Contacts
For the most part, Medicare does not cover routine vision care, glasses, or contact lenses. However, Medicare can make an exception
You may be wondering, How much does Medicare pay for glasses after cataract surgery? After your surgery, Medicare will cover 80% of the costs for prescription glasses or contacts, but you must purchase them through a provider who accepts Medicare assignment.
You will be responsible for the remaining 20%. Some beneficiaries have trouble getting Medicare to cover the pair of glasses or contacts.
If you are denied coverage, you can appeal the decision and request that they are covered. If you already paid for them out of your own pocket, you can request reimbursement.
You and your health provider can write a letter to add to your appeal, just be sure to state that you had met the requirements for cataract surgery, so your glasses or contacts must be covered.
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Does Medicare Cover Dry Eyes And Allergies
Though having dry eyes wont necessarily impact your vision, it can be a painful condition that affects your quality of life. Medicare will generally cover an exam to diagnose the problem since its not considered routine, at which point youll be on the hook for 20% coinsurance after youve met your Part B. Your Part D plan might also cover medication to treat the condition, though in some cases, over-the-counter treatment will suffice. Youll get similar coverage with a Medicare Advantage plan, and Medigap can help with your out-of-pocket costs if you have Original Medicare.
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What Is Refraction And Why Doesnt Insurance Always Cover It
A refraction is a test done by your eye doctor to determine if glasses will make you see better.
The charges for a refraction are covered by some insurances but not all.
For example, Medicare does not cover refractions because they consider it part of a routine exam and Medicare doesnt cover most routine procedures only health-related procedures.
So if you have a medical eye problem like cataracts, dry eyes or glaucoma then Medicare and most other health insurances will cover the medical portion of the eye exam but not the refraction.
Some people have both health insurance, which covers medical eye problems, and vision insurance, which covers routine eye care such as refractions and eyeglasses.
If you come in for a routine exam with no medical eye problems or complaints and you have a vision plan then the refraction is usually covered by your vision insurance.
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When Medicare Pays For Eye Exams And Glasses
Medicare only covers medical eye exams and relatedtreatments, with a few exceptions. Since Part A is your hospital coverage, coverage would only kick in if you suffer a traumatic eye injury or emergency that requires you to be admitted to the hospital. Most of your eye care will be covered by Part B.
Eye exams Medicare Part B covers
If you need a medical eye exam , your exam and care are covered by Part B.
Medicare Part B also covers cataract surgery, including the specific exams leading up to it. Heres when one of those previously mentioned exceptions appears: After cataract surgery, Medicare will cover one pair of conventional eyeglasses or conventional contact lenses after each surgery. This is the only time Medicare will pay for eyeglasses.
Medicare Part B also covers the following eye care services:
- An annual glaucoma screening for high-risk patients. You are usually considered high risk if you have a family history of glaucoma, are an African American over age 50, are a Hispanic American over age 65, or if you have diabetes.
- An eye prosthetic and certain maintenance of the prosthetic if you lose your eye due to trauma or surgical removal.
- Certain screenings, diagnostic tests, and treatmentsfor age-related macular generation.
- Contact lenses used to treat a medical condition.
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When Does Medicare Cover Cataract Surgery
Since cataract surgery can cost over $13,500 if you need surgery on both eyes, youre likely wondering if Medicare will cover cataract surgery.
Medicare covers standard cataract surgery for people who are 65 or older. Original Medicare will even pay for corrective lenses if you have surgery to implant an IOL. Under your Medicare Part B benefits, Medicare will pay for one pair of prescription eyeglasses with standard frames or a set of contact lenses.
But does Medicare cover laser cataract surgery? Luckily, the answer is yes. Medicare coverage includes surgery done using lasers.
Medicare Part B benefits only cover the Medicare-approved amount for cataract surgery. Youll also have to pay your deductible, plus a 20% Medicare Part B copay.
Determining Cataract Surgery Cost
Since most people who undergo cataract surgery in the U.S. have Medicare or private medical insurance, it can be somewhat challenging to determine the cost of the procedure for someone with no insurance coverage.
In such cases, many surgeons often charge the same fees for cataract surgery that they charge for an elective vision correction procedure called refractive lens exchange .
Refractive lens exchange is essentially the same procedure as cataract surgery, but the eye’s natural lens that is removed in RLE has not yet become clouded by a cataract. By replacing the eye’s natural lens with an IOL, the surgeon can correct significant amounts of nearsightedness or farsightedness, reducing the patient’s need for eyeglasses or contact lenses.
In 2019, the average cost of refractive lens exchange with a standard monofocal IOL implant was $3,783 per eye, according to a large survey of U.S. cataract and refractive surgeons.
For RLE with a toric IOL for astigmatism, the average cost was $5,304 per eye, and the average cost of RLE with a presbyopia-correcting IOL ranged from $4,704 to $6,898 per eye.
Cataract Surgery And Medicare
Now that you know a little more about Medicare and cataracts that dont require surgery, lets take a look at surgical options.
Cataract surgery is a simple procedure that involves replacing the natural lens in the affected eye with an artificial one. If you have cataracts in both eyes, youll likely have it performed on one eye at a time.
- Eye exams to diagnose serious vision problems
- Pre-surgery eye exams
- One pair of prescription eyeglasses or contact lenses after surgery
- Up to one year of follow-up care
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