Medicare and  Cataracts: Taking the Fear Out of Removing Cataracts

According to the World Health Organization, cataracts are the leading cause of blindness in the world. The most obvious symptom is clouded vision. The word “cataract” actually means “waterfall” because, with cataracts, it can seem like you’re looking through a sheet of water.

If you’re diagnosed with cataracts, this isn’t necessarily a cause for alarm. According to the National Eye Institute, this condition is a normal part of the aging process and is common among people over age 60. As such, Medicare covers the surgery required to correct cataracts, as well as glasses or lenses if they are necessary after the surgery.

According to the American Optometric Association, there are different types of cataracts: nuclear, cortical, and posterior subcapsular cataracts. These are found on different parts of the eye. If you have multiple cataracts, doctors typically remove them one surgery at a time. Cataracts in your other eye may be removed at a different time as well.

In cataract surgery, the natural lens of the eye that has the cataracts is removed and replaced by an artificial lens. The surgery can be performed on an outpatient basis, and only an ophthalmologist can perform this type of surgery.

Surgery isn’t necessarily the only way to deal with cataracts. Talk to your doctor about your options and what may be best for your situation.

Medicare coverage of surgery to correct cataracts

Talk to your doctor if you think you have cataracts.  Medicare doesn’t cover routine vision exams, but Medicare Part B does cover certain preventive and diagnostic eye exams. Ask your doctor if a diagnostic exam to check for cataracts would be covered by Medicare.

Some important things to know:

• If you’re getting the procedure as an outpatient, Medicare Part B covers the fees for the surgeon, the facility, the anesthesia, and the surgery both to remove the damaged natural lens with the cataracts and to replace it with an artificial, intraocular lens. You’ll pay the normal Medicare Part B cost sharing, which may include your Medicare deductible, and/or 20% of the amount approved by Medicare after you have reached your deductible. Medicare pays for any follow-up care after your cataracts are removed, subject to the Medicare coinsurance and deductible.

• If you’re getting the procedure as an inpatient, you’ll be covered under . Your costs may include the Part A deductible for each benefit period and/or daily coinsurance costs if your hospital stay exceeds 60 days. Check with your doctor if you’ll be admitted to the hospital as an inpatient or getting an outpatient surgery; this affects which part of Medicare you’re covered under and your costs.
• There’s always a chance that your surgeon doesn’t accept Medicare assignment (a payment agreement with Medicare where your doctor agrees not to charge you above the Medicare-approved amount for a medical service). If this happens, then you may have to pay a much higher amount for the surgery. To protect yourself from this possibility, check with your doctor to make sure that the surgeon slated to perform this surgery does, in fact, accept Medicare assignment. If not, have your doctor to refer you to a surgeon who does accept it. You can also find doctors and hospitals through Medicare.gov’s Physician Compare tool; simply filter your search results to only show providers that accept assignment.

• Medicare also pays for lenses and frames for one pair of glasses or contacts that your doctor prescribes after your cataracts are removed and an intraocular lens is inserted. You must get these glasses or contacts through a Medicare-approved supplier. Medicare covers the cost of lenses for both eyes (subject to deductible and coinsurance), even if the cataracts were only removed in one eye.

• Please note that Medicare will only pay for standard frames. If you’re uncertain as to which frames are Medicare eligible, ask your doctor or health-care provider for a list of eligible frames to avoid extra costs.

• Medicare doesn’t cover any additional costs for surgeries or procedures that are unrelated to cataracts.

• Generally, Medicare doesn’t cover vision correction eyeglasses, contacts, or LASIK surgery for reasons unrelated to cataracts. Medicare also doesn’t cover eyeglass “extras” like bifocals, tinted lenses, scratch resistant coating, or any contact-lens accessories. You’ll be responsible for any extra costs if you choose to get upgraded frames.

The Medicare Advantage (Part C) program also covers cataract surgery, since Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B. These plans may also include other benefits, like dental and hearing-related services, and sometimes provide more coverage. Some Medicare Advantage plans include prescription drug coverage (Original Medicare prescription coverage is limited), so they can give you health and medication benefits in one policy.

Some Medicare Advantage plans offer more complete vision coverage, such as routine eye exams and glasses (regardless of whether you’ve had cataract surgery). If you’d like help finding Medicare Advantage plan options that may include broader vision coverage, contact eHealth to speak with a licensed insurance agent today. Or, to start browsing plan options right away, just enter your zip code into the plan finder tool on this page.

For more information about how Medicare covers surgery to correct cataracts, you can call Medicare at 1-800-MEDICARE (1-800-633-4227, TTY users call 1-877-486-2048) 24 hours a day, seven days a week.

Sources

American Optometric Association, “Causes of cataracts.”

National Eye Institute, “Facts About Cataract.”

World Health Organization, “Priority eye diseases.”