Yes, Medicare covers cataract surgery, as long as a doctor determines the procedure as medically necessary. Cataracts occur as clouded areas in the lenses of your eyes that make it difficult to focus light. Surgery becomes a medical necessity when eye fogginess leads to visual impairment not correctable with eyeglasses or interferes with the treatment of other eye-related conditions.
Medicare Part B will typically cover 80% of the following aspects of outpatient cataract surgery:
- Pre-surgery eye exams
- The removal of the cataract
- Basic intraocular lens implants (IOL)
- One pair of eyeglasses or contact lenses post-operation
- Anesthesia
- Up to one year of follow-up care
Table of Contents
How Common Is Cataract Surgery?
More than half of all Americans over 80 years old have cataracts or have had them surgically removed. Cataract surgery offers lasting treatment and has become one of the most common, safest, and most effective medical procedures nationwide. Data shows that cataract removal significantly improves most seniors’ quality of life by restoring eyesight and allowing them to resume a more prominent role in personal and social activities.
How Does Cataract Surgery Work?
The type of cataract surgery and Medicare out-of-pocket costs will vary depending on the nature of your condition and the details of your plan. Nevertheless, outpatient procedures will mostly see coverage through Medicare Part B.
Eligibility Criteria
Cataract surgery must be deemed medically necessary for Medicare to help pay for it. Medicare will typically approve the procedure if a doctor certifies that one or more of the following circumstances occur:
- The cataract causes visual impairment not correctable by any other means and inhibits regular daily activities like reading, watching television, or driving.
- The cataract interferes with other required surgeries or medical monitoring to treat different eye conditions.
- Cataracts could lead to lens-induced diseases, such as glaucoma, threatening vision or ocular health.
- Alternative treatments or procedures could lead to cataract acceleration.
- The patient has experienced intolerable anisometropia or aniseikonia resulting from a lens extraction in the first eye.
Though Medicare occasionally considers special situations not listed above, lens opacity alone will not qualify for a covered surgery.
What Does Cataract Surgery Consist Of?
Cataract surgery typically occurs in an outpatient setting and takes less than an hour to perform. A doctor will dilate your pupil with eyedrops, apply a local anesthetic, and sometimes give you a sedative to encourage relaxation. They will then remove the clouded lens and implant a new artificial lens by one of two surgical methods.
Phaco
Phacoemulsification (phaco), the most common type of cataract surgery today, involves a doctor making a tiny incision in your cornea and inserting a needle-thin probe into the cataract. This probe uses ultrasound waves to break up the clouded area, then sucks out the fragments. Surgeons will leave the last layer of your lens intact as a resting place for the new artificial lens.
Extracapsular Cataract Extraction (ECCE)
Extracapsular cataract extraction (ECCE) involves a larger incision than phaco, allowing the doctor to remove the clouded lens in one piece using surgical tools. As with phaco, the back part of the lens remains as a resting point for the new artificial lens. Because of the larger incision, your cornea will require stitches to heal. ECCE most commonly applies to people with unique eye complications or those in less technologically advanced environments.
Which Medicare Parts Cover the Procedure?
Cataract surgery is typically an outpatient procedure and therefore is usually covered under Part B. However, depending on your plan and situation, other parts of Medicare could kick in to help with additional costs.
Medicare Part A
Though cataract removal typically proves a quick and easy outpatient procedure, more intricate surgeries in an inpatient hospital setting would receive some coverage from Medicare Part A. This coverage primarily includes the cost of room and board in an inpatient care facility for a set amount of days. Most inpatient doctors’ and surgeons’ services would still qualify for coverage under Medicare Part B.
Medicare Part B
Cataract surgeries primarily receive coverage from Medicare Part B. Upon meeting your Part B deductible ($226 in 2023), Medicare will pay for 80% of outpatient care, doctors’ services, and other qualified medical costs, leaving you to pay the remainder out-of-pocket in the form of a 20% coinsurance.
Medicare Supplement
Private companies provide optional Medicare Supplement insurance, or Medigap, plans to help absorb the out-of-pocket costs not covered by Original Medicare. Patients could use their Medigap policy to pay their share of the Part B deductible, coinsurance affiliated with their cataract surgery, and any relevant appointment or prescription copays.
What Does Medicare Not Cover?
Medicare will only cover medically necessary cataract surgeries implanting standard intraocular lenses. Advanced technology lenses or elective surgery to correct nearsightedness or astigmatism, also known as a refractive lens exchange, will not see coverage through Original Medicare. Though Medicare will pay for one pair of standard eyeglasses following the procedure, it will not cover upgraded frames or any eyewear from a non-Medicare-approved supplier.
Medicare beneficiaries without private Medigap coverage must pay their annual Part B deductible and all applicable coinsurance and copays accrued before, during, and after the procedure. More advanced or invasive cataract surgeries could significantly increase the overall cost of care, raising your Part B coinsurance simultaneously.
Where Can You Get Cataract Surgery?
Unless your condition necessitates a uniquely invasive procedure requiring inpatient hospital care, most cataract surgeries will occur at an ambulatory surgical center (ASC) or hospital outpatient department. ASCs focus on providing same-day surgical care and diagnostic services, offering a more convenient and often cheaper alternative to hospital-oriented procedures.
On the other hand, outpatient surgical centers (OSCs) are owned and operated by larger inpatient hospital centers. These facilities usually reside adjacent to their affiliated hospitals but can even function blocks or miles away in stand-alone buildings. Because OSCs follow their governing hospital’s regulations and price structure, most procedures will cost more than at ASCs. Out-of-pocket Medicare expenses average $320 at ASCs and $560 at OSCs.
How Does Medicare Advantage Cover Cataract Surgery?
As required by law, Medicare Advantage plans must provide all the same coverage and benefits as Original Medicare, including for medically necessary cataract surgery. Some Medicare Advantage policies will extend coverage to include certain prescription drugs, dental and hearing care, and extra vision benefits that could help lower the cost of cataract surgery and pay for advanced services or upgraded eyewear.
Because private insurers provide these policies differently, deductible and copay costs may vary. Regardless of these charges, patient out-of-pocket expenses cannot exceed the annual Medicare Advantage out-of-pocket maximum of $8,300 in 2023.
How Much Does Cataract Surgery Cost with Medicare?
The final cost of a Medicare cataract surgery will vary widely depending on the type of procedure performed, the surgical facility, the details of your plan, and potential complications during the operation.
The numbers on the chart below loosely estimate the final out-of-pocket Medicare costs for cataract surgery in one eye:
Price | |
|---|---|
Cost of Surgery | |
Medicare Coverage | $2,020 (80% covered by Medicare) |
Out-of-Pocket Costs | $505 (20% coinsurance) |
Part B Deductible | $226 |
Post Surgery Doctors Visit | $75 (approximate copays for three post-op check-ups) |
Other Treatment | |
Total | $806 or $1,231, depending on follow-up treatment |
For context, suppose you had an ECCE procedure performed in an ASC with no subsequent care. This scenario would cost significantly less than a phaco procedure performed at an OSC requiring anesthesia and follow-up retinal repair. Each factor raises your overall Medicare bill, thus increasing your coinsurance.
How To Get Medicare Covered Cataract Surgery
To begin securing Medicare coverage for cataract surgery, you will want to see an ophthalmologist to determine the level of care your condition requires. From there, you should obtain preauthorization from Medicare, schedule and undergo your surgery, and abide by all follow-up monitoring and maintenance instructions.
1. See An Ophthalmologist
To set up an eye examination, find a Medicare-approved ophthalmologist in your area. Gather all possible documentation about your eye history, existing conditions, and previous operations. Your ophthalmologist will refer to this information during their exam. Once settled on a final diagnosis, they will guide you through the details of your tentative surgery and instruct you on how to prepare.
Ophthalmologists undergo more advanced training than optometrists, can treat a broader range of conditions, and even perform surgery. Your ophthalmologist will often personally perform the cataract replacement procedure, though some may refer you to an outside specialist depending on the severity of your condition.
2. Obtain Preauthorization
Before scheduling your surgery, Medicare must preauthorize the operation as medically necessary. Check your Medicare policy and understand the depth of your coverage. Even if your condition makes you eligible for surgery, coverage can vary depending on the details of your plan and the ultimate procedure performed.
To prove medical necessity, your ophthalmologist will provide Medicare with your medical records and a letter of approval authorizing a Medicare-compliant operation. This letter must detail how surgery offers the only viable method of treating cataracts disrupting your daily life, interfering with other eye-related procedures, or meeting any of the other Medicare eligibility requirements for removal listed earlier in this article.
3. Schedule The Surgery
Your ophthalmologist will measure your eye to determine properly sized intraocular replacement lenses. From there, you can schedule an operation date with them or another Medicare-approved specialist. Your final decision depends on your access to participating Medicare providers in your area and whether you would like to receive care at an ambulatory surgical center (ASC) or outpatient surgical center.
To keep costs down, opt for a same-day operation at an ASC. Because ASCs specialize in one type of care, they can customize the patient experience and safety measures on a case-by-case basis.
4. Follow Post-Operative Care Instructions
After surgery, ensure you follow all post-operative care instructions. Arrange for a ride home from the medical facility, as you will likely need some time for your eyes to adjust and may experience drowsiness from sedatives or anesthesia. Your specialist will likely prescribe eyedrops and eyeshields to begin using as soon as you get home. Do not rub or aggravate your eyes and take over-the-counter medication as instructed for pain.
You typically must visit your ophthalmologist the day after surgery to inspect your new lenses and schedule subsequent checkups. Once the eyes have healed, you can meet with a Medicare-approved optometrist for new glasses or contact lenses.
Alternatives to Cataract Surgery
Though cataract surgery has proven a relatively simple and successful procedure nationwide, complications such as infection, drooping eyelids, retinal detachment, and even loss of vision can result in rare cases. Though concerning, these adverse side effects typically only occur in people with other overlying medical conditions. Either way, if you are not eligible for medically necessary cataract surgery or feel averse to the risks involved, consider the alternatives below.
Change Your Glasses Prescription
While a new eyeglass prescription would not directly treat cataracts, it could offer a way to skirt around the disease and temporarily correct blurry vision. Most cataract patients develop or experience increased nearsightedness, which their optometrists can amend with a stronger lens prescription for their current frames. Other eyewear that could temporarily alleviate cataract distress include anti-glare glasses, magnifying glasses, and prescription sunglasses for outdoor relief.
Improve The Lighting In Your Home
Since cataracts decrease your eyes’ light sensitivity and perceptive abilities, improving lighting conditions in your home could provide an adequate substitute for surgery. These improvements can include painting your walls with light reflective colors, maximizing daylight by installing oversized windows, and purchasing brighter light fixtures with sensors and controls for adjustability.
Adjusting Your Computer/Device Screens
If you cannot secure Medicare cataract coverage and frequently use a computer, smartphone, or other backlit devices, lower your screen brightness and color settings to reduce eye strain. If discomfort or fogginess persists, try sitting further away from your screen or purchasing blue-light-blocking prescription glasses. Some specialists believe that recent increases in cataract surgery could directly correspond with the widespread use of cell phones and computers in our modern society.
Putting It All Together
Cataract surgery is a relatively quick and effective procedure that removes clouded lenses from your eyes and replaces them with new intraocular ones designed to improve your vision. If cataracts disrupt your ability to participate in basic daily activities, Medicare should cover most of the costs of an eligible procedure. Talk to a Medicare agent to learn if you are eligible for cataract surgery and where to receive care.