Thursday, August 18, 2022

Will Medicare Cover Cataract Surgery

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When Does Medicare Cover Cataract Surgery

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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.

Questions To Ask Your Healthcare Provider About Cataract Surgery

Policies vary widely from one insurance provider to the next. Here are some questions you should ask your health care representative regarding cataract surgery:

  • How much is my deductible?
  • How much is my co-pay?
  • Does my plan pay for prescription eyeglasses after surgery?
  • Are you a preferred provider for any eye surgeons or surgery centers?
  • If my eye surgeon is not a preferred provider do I need to get your approval before covering the procedure?
  • Do you require advanced approval from a doctor to validate the medical necessity of my surgery?

In this article

Cataract Surgery Is Considered Medically Necessary

Cataracts are a disease of the lens in the eye, which is the organ behind the pupil that refracts light onto the retina, so the brain can process images of the world around you. There are several diseases that can affect the lens and therefore impact vision. Cataracts are one of the conditions that can lead to blindness over time.

This condition starts when proteins in the lens break down, leading to blurring or clouding of your vision. Damaged proteins will clump together in specific formations leading to loss of sight. You may also experience double vision, yellowing or fading vision, or cloudy spots in your line of sight.

Although many people develop cataracts because of an injury, disease, or congenital defect, most cataracts occur due to age. Everyones vision changes as they get older, but over the age of 40, cataracts become increasingly likely. After middle age, you may develop cataracts in one or both eyes.

The majority of cataracts that begin in middle age are small and do not affect your vision for many years. Most people do not experience serious problems driving, seeing objects, or performing activities until they are in their 60s.

Since cataracts affect older and elderly adults, it is important to know how insurance, especially Medicare, covers this condition. Although the federal health insurance program does not cover most vision issues, cataract removal is covered.

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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.

How Can I Know If My Lens Implant Is Covered

Does Medicare Cover Cataract Surgery? A Clear Look at Coverage

There are multiple types of cataract surgeries, and some of the more complex or involved procedures that will not be covered by Original Medicare. With most cataract surgeries, the type of lens that is used is called a monofocal lens. It is important to note that Medicare will only cover monofocal lens implants.

Lenses that arent covered by Medicare are:

  • Multifocal
  • Toric

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Do You Need Part D Coverage For Cataract Surgery

Generally speaking, you do not need Part D coverage for cataract surgery. However, there are some instances where it may prove useful. For example, if you need drugs prescribed after your surgery due to some special health conditions, these will likely be covered by Part D. If you do not have Part D, such medications may not be covered.

Most people will not need additional prescription drugs following cataract surgery, but this concern may be relevant to your situation. For this reason, it is wise to discuss the possibility of needing additional medication after your surgery with your physician beforehand, just so you know exactly what to expect.

How Much Does Medicare Cataract Surgery Cost With No Extra Coverage

According to Healthcare Bluebook, a fairly low-priced cataract surgery would be about $3,400 in 2020.1 Medicare Part B covers 80% of standard surgery once you meet your annual deductible.

For example, say you need cataract surgery on one eye, and it costs $3,420 for the standard procedure. You would need to pay 20% after you meet your deductible. The table below gives a breakdown of the costs:

Cataract Surgery
$203$887

The cost of your surgery will depend on several factors including the type of intraocular lens you get, the technology used, and the surgeon who performs it.

If you undergo laser cataract surgery, you will likely need to pay the added costs yourself. This is also the case if you receive a premium toric IOL for astigmatism or a presbyopia-correcting IOL.

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Cataract Surgery: Is It Medically Necessary

Medicare will only cover your cataract surgery if it is deemed as being medically necessary. In the majority of instances, procedures like cataract surgery will be deemed medically necessary. However, it will be useful to make sure that this is the case before you proceed with the surgery. Otherwise, if you discover that Medicare will not pay for it after the fact, it could put you in a real financial bind.

MORE ADVICE

Medicare will only cover your cataract surgery if it is deemed as being medically necessary.

How To Check My Coverage

Does Medicare Cover Cataract Surgery

In order to find out if your Medicaid plan provides coverage for vision services, you need to contact your state Medicaid agency. This agency can help you with:

  • Medicaid eligibility.
  • Liens and third-party liability.
  • Provider enrollment.
  • Lost Medicaid card or replacement.
  • Finding a Medicaid provider.
  • The status of a Medicaid application.

Because services vary from state to state, you need to speak with your states agency in order to get accurate information about your coverage.

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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.

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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How To Determine What Costs Medicare Will Cover

Although original Medicare covers most of the cost of cataract surgery, it is hard for any insurance company to know exactly what the surgical costs will be in advance. Medicare recommends the following steps on their website to ensure you know what will be covered and what you may have to pay out of pocket:

  • Ask your eye doctor, surgeon, or hospital about the specific costs of surgery and postoperative care.
  • Determine if you will need inpatient or outpatient care since they are covered by different Parts. Cataract surgery is typically outpatient care, but there are rare instances when an overnight stay in the hospital may be required.
  • Check with your other insurance programs, through Part C or otherwise, if they cover any aspects of cataract surgery.
  • Check your Part A deductible.
  • Check your Part B deductible because this part covers one pair of glasses or set of contact lenses to help your vision after cataract surgery in addition to other outpatient costs.
  • Medicare rulings state that patients are generally charged for portions of services that are not covered by the federal healthcare program. In the case of cataract surgery, this most often involves upgrades to the IOL.

    It is important to know that Medicare funds are managed at the state level, so the amount of coverage for bladeless cataract surgery could be different in different states. If you have questions about this cost, it is important to speak with your ophthalmologist and eye surgeon before proceeding.

    Does Medicare Cover Cataract Surgery In 2021

    Does Medicare Cover Cataract Surgery? Here

    In a word, yes. When medically indicated, cataract surgery is covered by Medicare and commercial insurances. Medically indicated means that the patient must be experiencing symptoms and have some disability from the cataract in some cases they may be required to meet certain visual acuity thresholds. Your eye doctor can help determine if a cataract is visually significant.

    With that said, there are a number of ancillary services and options that can be performed in conjunction with basic cataract surgery that are not covered by Medicare or commercial insurance. One example would be the type of lens implant placed during cataract surgery, non-covered IOL options include lenses that correct astigmatism and also those that correct presbyopia, allowing a patient to see at distance and up close without glasses.

    It is also important to note that despite cataract surgery being covered by Medicare and commercial insurance, it is still subject to deductibles, copays, and co-insurance. See this page to learn more about the cost of cataract surgery.

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    Discovering Cost And Coverage Before Cataract Surgery

    Before your pre-surgery eye exam, we recommend writing down some questions you have for your cataract surgeon. The questions can be general, as well as specific to you and your preferences.

    This will help you to remember the specific topics to discuss during your consultation and help you decide whether you should shop around for another eye surgeon that fits your requirements.

    What Are The Exclusions

    Though Medicare will cover both laser and traditional cataract surgeries, they do not yet cover New Technology Intraocular Lenses . For instance, Medicare may not cover you if you need multifocal or toric lenses, though they will cover monofocal lenses.

    You are also responsible for the 20% Medicare doesnt pay on standard treatments, as well as all deductibles and medications.

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    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.

    Are All Cataract Surgery Lens Options Covered By Insurance

    Does Medicare Cover Cataract Surgery?

    No, Medicare and commercial insurance only cover what are called monofocal intraocular lenses for cataract surgery. Premium upgrades to advanced technology lenses must be paid for out-of-pocket by the patient, these include toric lenses and multifocal and extended depth-of-focus lenses. See this page regarding the various lens options available when someone has cataract surgery.

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    Paying For Cataract Surgery

    Ultimately, insurance coverage greatly offsets the overall cost of cataract surgery, but even with coverage, patients still incur some out-of-pocket costs. Many insurance plans offer at least partial coverage for cataract surgery, but it may not be enough to cover everything.

    For individuals in need of financial assistance for vision care, many organizations across the country offer help. Depending on the organization, help can come in the form of financial support, free services, reimbursement and insurance assistance, and more.

    Visit Prevent Blindness to see if you qualify for any additional financial assistance for vision coverage.

    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?

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    Medicare Benefits For Corrective Lenses

    Though Original Medicare does not include a vision care benefit, corrective lenses following cataract surgery to implant an IOL is an exception. Corrective lenses can be a pair of eyeglasses or a single set of contacts. You are responsible for the coinsurance and deductible.

    To receive Medicare benefits for the eyeglasses, the supplier must be enrolled in Medicare and you need to select standard frames. If you want designer frames, you will owe the price differential to the supplier. If you are enrolled in a Medicare Advantage plan that covers vision care, check your plan benefits for any additional coverage for corrective lenses.

    ResourcesTo learn more about cataract surgery or eye health in general, it may be helpful to contact the American Academy of Ophthalmology or the National Eye Institute.

    Find Cheap Medicare Plans In Your Area

    Does Medicare Cover Cataract Surgery?

    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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    Does Medicare Cover Glasses After Cataract Surgery

    Cataract surgery is a relatively common and safe procedure. It helps improve the vision of many around the world.

    Usually you will see significant improvements in your vision after getting this surgery. However, its also likely you will still require eyeglasses after the procedure.

    You may have heard that Medicare generally does not cover the cost of vision care and glasses. And that is true in most cases. But what about after cataract surgery?

    That brings us to a common question many people have which is, Does Medicare cover Glasses After Cataract Surgery? In this article, we answer that question in clear, plain English. You will also find the average costs of corrective eyeglasses and other helpful info.

    What Does Cataract Surgery Typically Cost

    With or without Medicare coverage, cataract surgery costs a lot more at a hospital outpatient facility than at a standalone surgical center, also called an ambulatory surgical center.

    Under Medicares 2020 payment structure, the national average for allowed charges in outpatient hospital units was $2,021 for the facility fee and $557 for the doctor fee for surgery on one eye. Of the $2,578 total, Medicare paid $2,063 and the patient copayment was $515.

    Costs were significantly lower at standalone surgery centers, due to the difference in facility fees. The doctor fee was paid at the same level, $557, but the facility fee was $1,012, half the price for the hospital outpatient procedure. Of the $1,569 total, Medicare paid $1,256 and the copay was $313.

    Additional costs may apply patients with complex cases might require more than one doctor, for example. To reduce the chances of a surprise bill, request information from doctors, facilities and Medicare before the procedure.

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    Does Medicare Pay For Glasses After Cataract Surgery

    Although Original Medicare doesnt cover vision exams such as if you need everyday prescription glasses it will cover one pair of eyeglasses or contact lenses after cataract surgery of an implanted intraocular lens . Not everyone needs glasses after cataract surgery, but if you need post-cataract glasses for reading and other close-up tasks, you pay 20% of the Medicare-approved amount and Medicare Part B will pay for the contact lenses or eyeglasses from a supplier enrolled in Medicare.

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