Medicare covers surgery for cataracts, an eye condition that afflicts 68% of Americans who reach age 80. The Medicare Part B deductible and copay apply, and there are coverage limitations on the type of intraocular lens that is implanted and on recently developed surgical techniques. Cataract surgery is very safe and improves the vision of 9 out of 10 patients, according to the National Eye Institute.
Original Medicare, Medicare Advantage and Medigap offer different coverages
Medicare Part B covers 80% of the cost of medically necessary cataract surgery after the Part B deductible is met. If hospitalization is required — and that’s unusual — Medicare Part A pays. As with many other medical services, a Medicare Advantage or Medigap supplemental insurance may offer lower out-of-pocket costs for cataract surgery (but could also limit available providers). Contact the plan for details.
What factors affect the cost of cataract surgery?
Various circumstances will determine how much you pay for cataract surgery, which is usually performed on one eye at a time. The specific procedure employed by your surgeon, the length of the surgery and any underlying medical conditions can affect your cost.
The cost factors that patients are best able to control are their choice of Medicare plan and any supplemental coverage, and where the surgery is performed: standalone surgical center or hospital outpatient facility.
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 Medicare’s 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.
Questions you should ask:
Do you accept reimbursement from my Medicare plan?
What will be the doctor fee for the procedure?
Will the procedure be performed in a standalone surgery center or a hospital outpatient facility?
What other costs should I expect after the surgery?
Does Medicare cover other costs that come with cataract surgery?
Original Medicare doesn’t 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. You’ll pay more for fancier frames. Your supplier of corrective lenses must be enrolled in Medicare.
What coverage exclusions might apply?
Medicare covers traditional and laser cataract surgery, but has not yet begun paying for New Technology Intraocular Lenses (NTIOLS). For example, some toric lenses, designed to correct astigmatism, may not be fully covered. Discuss with your eye doctor whether it makes sense for you to pay more for the potentially greater improvement in vision.
Are there alternatives to surgery for cataracts?
Some patients may do well, at least in the early stages of cataracts, by taking measures to improve their cloudy vision without surgery. Brighter lights, anti-glare sunglasses, a magnifying lens for close activities, and updated prescription lenses can help. But when recommended by doctors, surgery is a safe and effective long-term solution.