Cataract surgery is a common medical procedure performed to remove clouding in the natural lens of the eye that causes blurred or impaired vision. During cataract surgery, the eye’s cloudy natural lens is removed and replaced with a clear artificial lens implant. This procedure aims to restore sharp vision.
After cataract surgery, some people need prescription eyeglasses for the first time to help optimize their vision with the artificial lens. Medicare provides coverage for medically necessary cataract surgery and also covers one pair of eyeglasses or contact lenses after each cataract surgery to correct any remaining vision problems and help patients fully recover from the procedure.
Medicare Coverage for Eyeglasses after Cataract Surgery
Medicare Part B helps pay for one pair of eyeglasses or contact lenses after each cataract surgery to correct vision problems caused by the surgery (1). Once you have cataract surgery, your prescription will change, so Medicare covers basic eyeglasses or contact lenses to provide you with adequate vision post-surgery.
According to Medicare.gov, “Medicare covers cataract surgery if it’s done using traditional surgical techniques or using lasers” (2). Cataract surgery inevitably alters your vision prescription, so Medicare covers one basic pair of glasses after each cataract surgery you undergo to restore your vision.
Medicare covers standard frames and lenses or contacts after cataract surgery. The coverage includes regular single vision, bifocal, trifocal or standard progressive lenses. Medicare does not cover other lens types like photochromatic lenses or additional coatings not deemed medically necessary.
It’s important to note that Medicare provides coverage for cataract surgery and related eyewear regardless of whether you’re enrolled in Original Medicare or a Medicare Advantage Plan. This benefit comes from Medicare Part B.
Sources:
(1) https://www.medicare.gov/coverage/eyeglasses-contact-lenses
(2) https://www.eyecareleaders.com/post-cataract-eyewear-medicare-coverage/
Medicare-Approved Amount
The Medicare-approved amount, also known as the allowable charge or payment allowance limit, refers to the maximum dollar amount Medicare will pay for a particular medical service or item. This approved amount is based on Medicare fee schedules and billing limits that are determined each year.
Medicare sets a limit on the approved amount for each service to ensure fair pricing. Providers who accept Medicare assignment cannot charge patients more than the Medicare-approved amount for covered services. This means that beneficiaries generally only have to pay the Medicare deductibles and coinsurance required by their specific Medicare plan.
Knowing the Medicare-approved amount helps beneficiaries estimate their potential out-of-pocket expenses if they see providers who accept Medicare assignment. It gives them peace of mind that they won’t face excessive or unexpected charges beyond what Medicare covers.
The approved amount limits beneficiaries’ liability and provides financial protection by capping the amount that providers can charge for services. While providers may charge more than the Medicare-approved amount, they can only collect up to the approved amount from Medicare and the patient combined.
Sources:
https://www.medicareinteractive.org/glossary/approved-amount
https://www.healthline.com/health/medicare/medicare-approved-amount
Medicare-Approved Amount for Eyeglasses
Medicare sets a specific allowable amount that it will cover for basic eyeglasses after cataract surgery. For 2022, the Medicare-approved amount is up to $100 for one pair of eyeglasses with standard frames and basic single vision or bifocal lenses. This $100 allowance is intended to cover the eyeglass lenses, frame, and basic fittings associated with the eyeglasses.
The $100 Medicare-approved amount applies to the entire pair of eyeglasses. That means the allowance for the frames and for the lenses combined must total $100 or less. You cannot allocate $50 for the frames and $50 for the lenses – the total billed to Medicare must be $100 or under.
It’s important to note that the $100 Medicare-approved amount has not increased since the benefit was introduced in 1999. So while costs and options for eyewear have expanded over the past 20+ years, the Medicare allowance has remained stagnant at $100.
Upgrades and Out-of-Pocket Costs
Original Medicare covers basic eyeglasses after cataract surgery, but beneficiaries may choose to upgrade their lenses, frames, or coatings for an additional out-of-pocket cost. Some common add-on options include:
- Progressive lenses – These provide a gradual transition in vision correction rather than a distinct line. Medicare does not cover progressive lenses, so beneficiaries pay the full cost if they select this upgrade.
- Anti-reflective coating – This reduces glare and reflections. Medicare does not cover anti-reflective coatings, making them a fully out-of-pocket upgrade.
- Scratch-resistant coating – This protects eyeglass lenses from scratches. Medicare does not cover scratch-resistant coatings as they are considered an upgrade.
- Polarized or photochromic lenses – These tint or darken when exposed to sunlight. Again, these lens options are not covered and require full out-of-pocket payment.
- Designer frames – Medicare covers basic plastic or metal frames. Fashionable frames from designer brands are not covered and require additional payment from the beneficiary.
Beneficiaries should be aware of these potential upgrade costs when selecting their post-cataract surgery eyeglasses. The provider can explain which options are fully covered versus upgrades requiring out-of-pocket expenses. Carefully reviewing the costs of upgrades will help beneficiaries make informed choices for their vision needs.
Source: https://www.medicare.gov/coverage/eyeglasses-contact-lenses
Types of Eyeglasses Covered
After cataract surgery, Medicare covers 1 pair of eyeglasses, which includes a basic frame and standard plastic lenses. The types of lenses covered include:
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Single vision lenses – correct vision in one eye
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Bifocal lenses – correct near and far vision
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Trifocal lenses – correct near, intermediate, and far vision
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Standard progressive lenses – correct vision at all distances
Medicare will cover basic plastic lenses, but not upgrades like tinting, scratch coating, or transition lenses. Any extra features beyond basic plastic lenses must be paid out-of-pocket by the patient.
Medicare also covers standard eyeglass frames, but will not pay for upgraded designer frames. Patients may choose upgraded frames but must cover the difference in cost themselves.
There are some limitations on the types of eyeglasses covered. For example, Medicare does not cover contact lenses or two pairs of glasses. Patients are only entitled to one pair of basic eyeglasses after cataract surgery (1).
(1) https://www.medicare.gov/coverage/eyeglasses-contact-lenses
Eyewear Providers Accepting Medicare
When getting eyeglasses after cataract surgery covered by Medicare, it’s important to check that the eyewear provider you choose accepts Medicare assignment. This means they accept the Medicare-approved amount as full payment for the eyeglasses.
Some national optical retail chains like LensCrafters, Target Optical, Sears Optical, and JCPenney Optical accept Medicare assignment. You can also find independent optometrists and opticians that take Medicare assignment for cataract eyewear in your area.
Recommend checking with providers to ensure they accept Medicare assignment for cataract eyewear. You want to avoid any surprise bills and out-of-pocket costs beyond the Medicare-approved amount. The provider should be able to confirm if they accept assignment before providing you with eyeglasses.
You can also search for eyewear suppliers in your area that accept Medicare on Medicare.gov. This helps ensure you choose a provider that will bill Medicare directly and not charge more than the approved amount.
Submitting Claims and Receipts
After getting eyeglasses or contact lenses post-cataract surgery, you need to submit receipts and claims forms to Medicare to get reimbursed for your costs. Here’s how the process works:
First, make sure to get an itemized receipt from your eyewear provider. This receipt should include the date of service, a description of the eyewear provided, and the amount charged. The receipt is your proof of payment.
Next, you need to complete the Medicare claim form to submit. This is CMS-1500 form for Part B medical claims. You can download the form from the Medicare website here. Fill out the form with your personal information, Medicare number, date of services and details about the provider and services rendered.
Attach the itemized receipt to the completed claim form. Make copies of all documentation for your records before sending.
The claim must be submitted within 12 months of receiving the eyeglasses/contact lenses for Medicare to reimburse you. Submit the claim form by mail or electronically to your Medicare administrative contractor.
You can expect to receive reimbursement from Medicare within 30-60 days if your claim is approved. The reimbursement amount will be up to Medicare’s approved limit, which may not cover the full cost of your eyewear.
Coverage Time Limits
Medicare generally covers one pair of eyeglasses after cataract surgery as long as certain conditions are met. There is a time limit for when you must obtain the eyeglasses to be eligible for Medicare coverage:
According to Medicare.gov, you must get your eyeglasses within 12 months of cataract surgery to have Medicare help pay for them. This means you have up to one year after the cataract is removed to get your post-surgical eyewear and submit the claim to Medicare.
It’s important to note that the 12 month timeframe is based on the date of the second cataract surgery if you have both eyes done. For example, if you have cataract removal on your right eye in January and left eye in June, the 12 month timeline would begin in June after the second procedure.
Some sources like the Centers for Medicare and Medicaid Services state you have no more than 6 months after each cataract surgery to obtain your eyeglasses for that eye. However, most experts agree you actually have up to 12 months after the second eye’s procedure to get glasses for both eyes.
The key is that you must receive your Medicare-covered eyeglasses within one year from the date of your last cataract operation to be eligible. Otherwise, you’ll be responsible for the full cost out of pocket.
Conclusions
In summary, Medicare provides coverage for one pair of eyeglasses or contact lenses after cataract surgery. The Medicare-approved amount covers basic frames and plastic lenses. Beneficiaries have an out-of-pocket cost for upgrades such as progressive lenses, anti-reflective coating, and premium frames. It’s recommended that beneficiaries check with their eyewear provider to determine the exact out-of-pocket costs for any upgrades. Medicare will only cover eyewear from a provider enrolled with Medicare. Claims need to be submitted within one year of cataract surgery. It’s important for beneficiaries to understand these key details of Medicare’s coverage for eyeglasses after cataract surgery.
