Is Cataract Surgery Covered by Medicare Advantage Plans?

Medicare Advantage Coverage for Cataract Surgery

Depending on the nature of your surgery, Medicare Part A or Part B will cover some of the costs. For example, if you get cataract surgery at an outpatient clinic, it will likely be covered under Part B, which is included in your Medicare Advantage plan. If you require hospitalization as a result of the surgery, Part A will typically cover a portion of the costs, as well.

You can expect Medicare Advantage to provide full or partial coverage for the following:

• Vision appointments prior to the surgery
• Cataract surgical procedure
• Intraocular lenses
• Outpatient services after the surgery
• The cost to stay in the hospital overnight (if needed)

It’s important to understand exactly when and how Medicare covers cataract surgery. In most cases, your Medicare Advantage plan will only cover the surgery if your doctor deems it medically necessary. That said, Medicare will only cover the surgery when standard intraocular lenses are used. If you get elective cataract surgery or surgery using more advanced lenses, Medicare may not cover it.

Keep in mind that you may be limited to in-network providers with a Medicare Advantage plan. You may only be able to get coverage for cataract surgery if it meets the aforementioned requirements and is carried out at a facility that's within your approved network. It’s also important to consider that you could still pay certain out-of-pocket costs for the surgery. For example, if you haven’t met your Medicare Advantage plan’s deductible for the year, you may need to pay for the surgery until your deductible has been met. Then, you’ll generally be required to pay 20 percent of the cost of the surgery (with your plan covering the rest).

You could have to pay additional costs, depending on the vision benefits offered through your plan. If you must pay a copay for vision care, then this will still apply when you’re diagnosed. After cataract surgery, you’re generally covered for one pair of corrective glasses or contact lenses, but how much you’ll pay will vary based on your plan’s vision benefits. With some plans, you may not have to pay anything for after-surgery prescriptions, but with others, you might still have a copayment.

Does Original Medicare Cover Cataract Surgery?

Original Medicare does cover cataract surgery. Just like Medicare Advantage, Original Medicare will cover 80 percent of the cost of the surgery, as long as it is medically necessary and only uses intraocular lenses. One benefit of using Original Medicare coverage for cataract surgery is that you don’t have to worry about getting the procedure done in a specific network; as long as the clinic accepts Medicare, you can expect your surgery to be covered.

Like Medicare Advantage, Original Medicare will also cover one post-surgery prescription for corrective eyeglasses or contact lenses. However, Original Medicare does not offer any other routine vision benefits, which means that coverage for eye care only applies to cataract surgery and a one-time prescription of eyewear. You will not get any of the common, ongoing vision coverage offered with Medicare Advantage plans, such as routine eye exams, or replacements for eyeglasses or contacts.

How Much Does Cataract Surgery Cost With Medicare?

On average, cataract surgery can cost anywhere between $3,500 and $7,000 per eye before insurance.3 With these numbers, you may pay between $700 and $1,400 per eye out of pocket, not including any applicable copays and deductibles. Though you may still have to pay for part of the surgery and related treatments, a Medicare Advantage plan (with or without vision benefits) could reduce your out-of-pocket costs.

If you need help finding a Medicare Advantage plan to cover cataract surgery, be sure to check out SeniorLiving.org’s top recommendations for Medicare Advantage.

Does Medicare Advantage Cover Vision Services After Cataract Surgery?

Both Original Medicare and Medicare Advantage will cover the first pair of corrective eyeglasses or contact lenses you need after cataract surgery. Beyond this benefit, you’ll need to depend on your Medicare Advantage plan’s vision benefits for any additional coverage. Fortunately, many Medicare Advantage plans offer free routine eye exams and eyeglass fittings as well as free or low-cost frames and lenses. You may also get coverage for LASIK eye surgery. Just remember that these vision benefits can vary between Medicare Advantage plans, and you may be limited to in-network care, so make sure to find out what your carrier covers beforehand to avoid hefty out-of-pocket costs.