Cataracts are a clouding of the natural lens in the eye that affects vision. As people age, the lens can become cloudy and harden, causing blurred or hazy vision. Cataracts often develop slowly and painlessly. Many people over the age of 60 have cataracts to some degree, making cataracts a very common age-related eye condition.
Cataract surgery is a procedure to remove the cloudy natural lens and replace it with a clear artificial lens to restore vision. It is the most commonly performed eye surgery today. During cataract surgery, the surgeon makes a tiny incision in the eye to break up the cloudy lens using ultrasound waves and suction. The artificial replacement lens is then inserted in its place. Cataract surgery is typically done on an outpatient basis and takes less than an hour to perform. Most people experience improved vision after cataract surgery.
What are Cataracts?
Cataracts are a clouding of the lens in the eye that affects vision. According to the American Academy of Ophthalmology (AAO), cataracts occur when proteins in the eye’s lens break down over time, causing the lens to become cloudy and obstruct light from entering the eye properly. This clouding prevents clear vision.
Cataracts typically develop slowly over many years and affect people differently. Some common symptoms are blurry vision, faded colors, halos around lights, trouble with bright lights, and trouble seeing at night. As cataracts progress, vision loss increases.
There are several factors that increase the risk of developing cataracts, including aging, UV exposure, smoking, diabetes, certain medications, eye injury/surgery, and family history. However, cataracts are extremely common, especially in older adults. By age 80, more than half of all Americans have cataracts or have had cataract surgery, according to the National Eye Institute (NEI).
When is Cataract Surgery Needed?
Cataracts surgery is generally recommended when cataracts start to impair vision and interfere with normal daily activities (Center for Eyecare, 2023). Some common symptoms and vision impairments that indicate cataract surgery may be needed include:
Blurry vision – Cataracts can cause blurry vision, making it difficult to read, drive, recognize faces, and perform other visual tasks. As cataracts worsen, blurry vision becomes more constant (The New York Eyedoctor, 2023).
Impaired night vision – Cataracts cause added difficulty seeing and driving at night. Headlights and street lights can appear overly bright or have halo-like rings around them (Virginia-Lasik, 2023).
Faded colors – Colors may start to look faded or yellowed. Reds and blues become less vibrant (Center for Eyecare, 2023).
Double vision – Cataracts can cause double vision in one eye. Two images are seen instead of just one (The New York Eyedoctor, 2023).
Glare sensitivity – Bright sunlight, lamps, reflective surfaces, and oncoming headlights can cause increased glare and difficulty seeing (Virginia-Lasik, 2023).
Impaired reading vision – Up-close activities like reading and sewing become challenging. Reading may require brighter light and holding reading materials farther away (Center for Eyecare, 2023).
Frequent prescription changes – Changes in eyeglass or contact lens prescriptions may be needed more often to compensate for worsening vision from cataracts (The New York Eyedoctor, 2023).
Medicare Coverage for Cataract Surgery
Medicare provides coverage for cataract surgery for beneficiaries aged 65 and over. Both Medicare Part B and Medicare Advantage plans cover the procedure. The coverage includes the surgery itself as well as pre-operative and post-operative care.
Medicare Part B covers 80% of the Medicare-approved amount for doctor services for cataract surgery after you pay the Part B deductible. This includes the surgery and services immediately before and after the operation. The 20% coinsurance is typically covered by supplemental insurance like Medigap or you pay out-of-pocket.
Medicare Advantage plans must cover all medically necessary services that Original Medicare covers, including cataract surgery. However, costs vary between Medicare Advantage plans. Many have low copays or coinsurance for the surgery when using in-network providers.
The specific services and costs that Medicare covers for cataract surgery include:
- Presurgical exams by an ophthalmologist
- The surgery itself, including the surgeon and operating room fees
- Insertion of an artificial lens (IOL or intraocular lens)
- Post-surgical care like exams, medication, eyeglasses or contacts
Medicare does not cover costs considered not medically necessary like premium IOLs that correct astigmatism or provide multifocal vision. You would need to pay out-of-pocket for those upgraded lens options.
Medicare Part B Coverage
Medicare Part B covers doctor fees, certain prescription drugs, and medical equipment and supplies, including for cataract surgery.
Under Medicare Part B, standard cataract surgery and associated pre-operative and post-operative care are covered benefits. This includes the surgeon’s fees, fees for other doctors involved in the surgery like anesthesiologists, and costs associated with the facility where the surgery is performed.
Medicare Part B will cover the basic monofocal lens implanted during cataract surgery. Any upgraded premium intraocular lenses will have additional out-of-pocket costs.
Medicare Part B also covers corrective lenses (eyeglasses or contact lenses) after cataract surgery with an allowance. In 2023, Medicare covers up to $100 for one pair of eyeglasses or $200 for contact lenses after each cataract surgery.
For cataract surgery, Medicare Part B covers 80% of the Medicare-approved amount after you meet the yearly Part B deductible. You will be responsible for the remaining 20% coinsurance.
It’s important to note that while Medicare Part B covers the standard medical costs associated with cataract surgery, it does not cover related services like transportation to medical appointments or post-operative help at home.
Medicare Advantage Coverage
Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. These plans bundle Medicare Part A, Part B, and usually Part D into a single plan.
Medicare Advantage plans must cover all services that Original Medicare covers, including cataract surgery. However, costs and coverage rules can vary between plans. Many Medicare Advantage plans offer additional benefits beyond what Original Medicare covers, which may help reduce out-of-pocket costs for cataract surgery.
For example, some Medicare Advantage plans cover basic cataract glasses or upgraded intraocular lenses after cataract surgery, which aren’t covered by Original Medicare. Plans may also have different copays, coinsurance, or deductibles for cataract surgery compared to Part B.
Beneficiaries should review their specific Medicare Advantage plan’s cataract surgery coverage, costs, and provider network rules before scheduling surgery. Getting cataract surgery done out-of-network may lead to higher out-of-pocket costs. Working with an in-network surgeon and facility is the best way to minimize expenses.
In general, Medicare Advantage provides robust coverage for cataract surgery and related eyecare, but the specifics depend on each plan’s coverage details. Comparing options during open enrollment can help choose a plan with cataract surgery benefits that suit your needs.
Out-of-Pocket Costs
Original Medicare covers 80% of the approved cost for cataract surgery. Beneficiaries are responsible for the remaining 20% as coinsurance, which can run from $500 to $3000 or more out-of-pocket per eye, depending on the costs in your area.
There are some costs associated with cataract surgery that aren’t covered by Medicare at all. These non-covered services can include:
- The cost of premium intraocular lenses (IOLs) – Medicare covers only basic monofocal lenses, so you pay the difference in cost for prescriptions or toric lenses out-of-pocket.
- Routine eye exams before or after surgery.
- Post-surgery corrective lenses or glasses.
- Transportation to and from the surgery center.
Many beneficiaries purchase supplemental insurance like Medigap or have additional retiree coverage to help pay for these out-of-pocket costs associated with cataract surgery. Otherwise, these expenses come directly out of your own pocket.
Supplemental Insurance
Medicare beneficiaries can reduce their out-of-pocket costs for cataract surgery by getting supplemental insurance. Two common types of supplemental insurance are Medigap plans and retiree health plans from a former employer.
Medigap plans are sold by private insurance companies and help fill coverage gaps in Original Medicare. Some Medigap plans cover the Medicare coinsurance for cataract surgery, reducing your out-of-pocket costs. Depending on the plan, Medigap may also cover your Medicare Part B deductible.
Retiree health plans from a former employer can provide similar benefits to Medigap for Medicare-approved services like cataract surgery. These plans may pay some or all of the Medicare coinsurance. Some plans also reimburse your Medicare Part B deductible. Check with your retiree health plan administrator for specific cataract surgery coverage details.1
Getting supplemental insurance can significantly reduce what you pay out-of-pocket for cataract surgery covered by Medicare. Comparing Medigap and retiree plan options can help you choose the right supplemental coverage.
Cataract Surgery Costs
The cost of cataract surgery can vary greatly depending on whether you have health insurance coverage. According to Health Partners, the average estimated cost for cataract surgery on one eye without insurance is between $3,500 and $6,000 (https://www.healthpartners.com/blog/does-medicare-cover-cataract-surgery/). However, with insurance such as Medicare, out-of-pocket costs are significantly lower.
For those with Medicare Part B, typical out-of-pocket costs for standard cataract surgery on one eye range from $0 to $1,000. This covers the Part B deductible and 20% coinsurance. Those with Medicare Advantage plans pay anywhere from $0 to $2,000 out-of-pocket on average, but this can vary significantly by plan (https://www.forbes.com/health/medicare/does-medicare-cover-cataract-surgery/).
Supplemental insurance like Medigap can help cover Medicare out-of-pocket costs. Overall, cataract surgery is usually fully or mostly covered by Medicare and additional insurance, making it affordable compared to the total costs without insurance.
Conclusion
In summary, Original Medicare Part B covers a portion of the costs for cataract surgery, including the surgeon’s fees, the facility fees, and required preoperative and postoperative exams. Medicare pays 80% of the approved amount after you meet your Part B deductible. This coverage extends to both traditional Medicare and Medicare Advantage plans, though the rules may vary between plans.
For the remaining 20% coinsurance, you may need to pay some out-of-pocket costs depending on if you have supplemental insurance. Many Medicare Advantage plans also help limit out-of-pocket expenses for cataract surgery to a set copay. The total costs for cataract surgery in the US normally range from $3,000-$6,000 per eye depending on factors like the area and intricacy of the procedure. While Medicare covers a portion of cataract surgery, understanding your potential out-of-pocket expenses is an important part of planning surgery.
