How Much Does Medicare Pay for Cataract Surgery? 

Your eyesight is one of your most important senses, but it is also one of the commonly affected senses as you age. Many seniors find that their eyesight isn’t what it used to be, but for many seniors, corrective lenses or contacts can usually remedy the problem and restore 20/20 vision.

There are, however, some eye conditions that require more intensive treatment. Glaucoma is a common concern among seniors as are cataracts. In the latter condition, eyesight diminishes over time, and it may not become apparent that there’s a problem until cataracts have become severe.

What Are Cataracts?

A cataract is a clouding of the lens of the eye that is made up of denatured proteins. Most cataracts take years to form, and from the outside, a cataract appears as a milky or cloudy haze over the lens of the eyeball. It is most noticeable over the pupil, or the black part of the eye. Cataracts may develop in both eyes, but some people experience the development of a cataract in only one eye.

From the perspective of the individual suffering from cataracts, vision may appear blurry or faded. Without treatment, cataracts can lead to total blindness. Light sensitivity may also accompany the development of a cataract, and someone with cataracts may also experience a halo-like feature around lighted objects.

How Are Cataracts Treated?

Treatment for cataracts can vary depending on the cause and the severity. For some seniors, cataracts develop simply due to aging and a denaturing process of eye lens proteins. For others, diseases and medical conditions like hypertension and diabetes can contribute to the development and worsening of cataracts.

For the vast majority of cataract sufferers, surgery is the only way to truly address the problem. Other treatments may include dietary changes, lifestyle adjustments and medications. Ultimately, the only true way to treat a cataract is to remove the affected lens. This is typically done using lasers for pinpoint accuracy.

Once removed, this lens is replaced with an artificial lens. For most people, cataract surgery is an outpatient procedure that can be completed in about 20 minutes, but you can expect to spend at least 30 minutes in recovery following the surgery. Including prep time, the procedure and the immediate recovery period, you can expect to spend at least a couple of hours for the entire process. Full recovery can take between four and eight weeks.

Does Medicare Cover Cataract Surgery?

Original Medicare benefits cover cataract surgery in most cases. Coverage is supplied by Medicare Part B since cataract surgery is an outpatient procedure. Even if you have your surgery performed at a hospital, Part B provides coverage unless you are admitted. Any type of inpatient coverage is supplied by Medicare benefits under Part A while Part B of your Medicare coverage supplies outpatient benefits.

It’s important to note that Original Medicare does not supply benefits for general vision care. This means that services like eye exams, glasses and contacts and most optometrist services are not covered by Medicare. Additionally, Medicare benefits do not cover the cost of vision correction surgery or any type of cosmetic surgery related to your eyes.

The difference with cataract surgery is in the fact that this procedure involves the placement of an artificial lens. In this case, Medicare does supply coverage for the surgery itself as well as for the artificial lens, also known as an intraocular lens.

Additionally, Medicare benefits will typically supply coverage for one pair of corrective lenses to be worn during your recovery period. Any glasses, including frames, that are covered by Original Medicare during recovery are a one-time benefit per surgical procedure. If you require corrective lenses following cataract surgery, this does not mean that Medicare will continue to pay for corrective lenses in the future.

How Much Does Medicare Pay for Cataract Surgery?

In terms of how much Medicare pays for cataract surgery, the standard coinsurance amount is a 20/80 split. This means that you pay 20% of the cost of the surgery while Medicare pays the remaining 80%. Keep in mind that you must have met your deductible for the benefit period in order to receive this rate. If you have not met your deductible, you will be responsible for paying your deductible amount plus the coinsurance amount of the remaining balance after your deductible.

In terms of aftercare, Medicare will cover follow-up visits with your doctor to check on the progression of your recovery. If medications are required to assist in recovery or to treat things like infections that arise from your cataract surgery, Medicare Part D may supply coverage.

In order for medications to qualify for coverage, they will need to be listed in your plan’s formulary. If a medication is needed but not listed in your formulary, you may need to file for an exception waiver to get approval. This process typically needs to involve the help of your doctor and/or surgeon. Your costs for medications under Part D will be based on your plan and provider.

Does Medicare Advantage Cover Cataracts?

Medicare Advantage is very similar to Original Medicare in that it supplies inpatient and outpatient benefits. Like Original Medicare coverage, Medicare Advantage will cover cataract surgery under Part B along with corrective lenses if required. Inpatient care is still supplied by Medicare Part A.

The difference is that many Medicare Advantage plans provide additional benefits on top of those supplied by Original Medicare. These additional benefits differ from plan to plan and provider to provider, but they may include access to additional therapies to aid in vision health.