If you’re new to Medicare or making different elections for the coming year, you may be wondering about specific coverage areas. For instance, can Medicare help with eye health, namely cataract surgery?
Medicare — the federal health insurance program for people age 65 and older, as well as certain people with disabilities younger than 65 — can help you get this corrective surgery and post-surgery vision care.
[SEE: Things You Should Know About Medicare.]
Importance of Cataract Surgery for Vision Health
Cataracts are common among older adults. They develop when proteins in your eye break down and cause a clouding of the natural lens. This lens bends and refracts light rays that come into the eye, so when it gets cloudy, what you see can look hazy — like looking through a foggy window.
Cataracts can impact your safety as your vision decreases, and they can eventually lead to blindness. The good news is that surgery is an effective treatment option.
During cataract surgery, your surgeon will remove the eye’s cloudy natural lens and replace it with a clear artificial lens. Called an intraocular lens, or IOL, this plastic device works just like your natural lens did when it was clear.
[READ: Does Medicare Cover Eye Exams?]
Does Medicare Cover Cataract Surgery?
Yes, Medicare covers cataract surgery.
More specifically, original Medicare (Part A and Part B) covers the diagnosis and treatment of cataracts, including laser surgery, says Bob Rees, chief sales officer with eHealth Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.
However, Medicare only covers cataract surgery when it has been deemed “medically necessary,” which means the cataracts are causing significant vision impairment. When corrective lenses are no longer enough for you to complete daily tasks, then you’ve probably met the threshold for medical necessity. Your ophthalmologist can advise you on that diagnosis.
[READ: Foods That Are Good for Your Eyes.]
Types of lenses covered by Medicare
Medicare only covers standard cataract surgeries that involve the implantation of an IOL.
“Other forms of cataract surgery typically aren’t covered,” Rees notes.
Medicare also doesn’t cover advanced technology lenses or surgeries that are deemed elective, such as those to correct nearsightedness or astigmatism.
Eyeglasses coverage after cataract surgery
After the surgery, Medicare Part B will cover the cost of one pair of corrective glasses or contacts up to an allowed amount. However, you may have to pay some out-of-pocket costs.
“For glasses, the coverage only extends to basic frames and lenses, so you may also pay more if you get fancier ones,” Rees says.
What’s more, he notes, you have to get said lenses from the right provider.
“(Original) Medicare will only pay for your post-cataract surgery glasses or contact lenses from a supplier enrolled in Medicare. It’s not enough for them to bill Medicare for you; they must be a Medicare-enrolled supplier,” Rees explains.
Do Medicare Advantage Plans Cover Cataract Surgery?
Yes, Medicare Advantage plans cover cataract surgery. Some plans also offer additional vision services coverage.
You’ll need to check your plan for details and make sure you’re using an in-network provider.
Do I Need Medicare Supplement (Medigap) to Cover Cataract Surgery?
You do not need supplemental insurance to cover cataract surgery. For those who have chosen original Medicare, however, Medigap plans can help you cover any out-of-pocket costs.
Cataract Surgery Costs and Lenses
Cataract surgery is usually conducted as an outpatient procedure. Medicare Part B covers the cost of the surgery once you’ve met your deductible. In 2024, the annual deductible for all Medicare Part B enrollees is $240.
If you have original Medicare, you’ll be responsible for 20% of the cost of surgery, after you’ve met the deductible. If you have a Medigap plan, you may be able to get additional coverage for that 20%. If you have Medicare Advantage, you’ll be responsible for your plan’s cost sharing.
According to Medicare.gov’s Cost Lookup tool, cataract surgery costs $1,101, on average. That amount is simply the fee for the facility. Your specific surgery may involve additional steps, which may also add to the cost.
Of the estimated $1,101 listed above, Medicare would pay $880, leaving $220 for the patient to pay out of pocket.
The surgeon’s fee can increase this total significantly. Generally speaking, cataract surgeries run about $3,000 to $5,000 in total, depending on the complexity of the case, the doctor’s fee schedule and the location where the surgery is being performed.
The key here is to make sure you understand ahead of time what your financial responsibility will be when scheduling your surgery.
Bottom Line
Vision health is a key component of overall health and wellness, and you don’t need to accept clouded vision as part of getting older. Talk with your doctor about what you can do to address cataracts, and check your Medicare plan details for more information.
If you need help understanding or navigating your Medicare benefits, visit Medicare.gov or reach out to the Centers for Medicare and Medicaid Services’ call center at 1-800-Medicare.
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originally appeared on usnews.com
Update 04/24/24: This story was previously published at an earlier date and has been updated with new information.
