Does Medicare Cover Cataract Surgery?

Staff Writer
Eye Exam Molly Johnson/YouTube

Cataracts cause the lens of your eye to become clouded. Once this condition progresses, your doctor will start talking about surgery to remove the cataracts. But do you have Medicare cataract coverage? Read on to learn more about what cataracts are and what to expect from Medicare.

What Are Cataracts?

Cataracts form when the lens, which is the clear part in the front of your eye, becomes clouded. Your lens is normally clear, but when you develop cataracts, the lens becomes blocked when proteins within it start to break down. The exact cause isn't clear, but most researchers believe that cataracts are caused by normal aging processes.

The clouding of your lens affects the way light enters your eye and prevents your brain from processing images the way it should. That's what causes the blurry vision that you might already be experiencing. Most people start experiencing issues with cataracts in their 60s, although cataracts can occur in younger people too. The condition could affect just one eye, or it could affect both.

When Is Surgery Recommended?

In the early stages of having cataracts, your doctor may recommend that you use anti-glare glasses and sunglasses or brighten the lighting in your home to help improve your vision. These accommodations may only work for so long, however. Once your vision becomes impaired to a certain point and starts interfering with your ability to live your life comfortably, your doctor will likely start talking about surgery.

Your doctor might also choose to perform cataract surgery if the presence of cataracts makes it more difficult for the physician to treat another eye condition you have or to examine your eyes. You might have an eye condition, such as diabetic retinopathy, that requires your doctor to see into the back of your eye. A cataract can make this difficult or almost impossible, so the physician may recommend surgery in order to make it easier to manage your other vision issues.

When your doctor performs cataract surgery, they remove the cataract and replace your clouded lens with a clear artificial one. This procedure is typically done as outpatient surgery, meaning you get to go home the same day, and lasts around an hour. Complications are rare with cataract surgery. However, if you have another eye condition, the surgery has a higher risk of causing complications. Your doctor may try to treat the other condition first before you both agree to pursue cataract surgery. This can lessen your risk.

Medicare's Guidelines for Cataract Coverage

Undergoing surgery is stressful enough without worrying about whether your insurance covers the procedure or not. You might also be aware that Medicare doesn't cover routine eye exams for glasses or contacts. In addition, cataract surgery is often considered an elective procedure. Thankfully, by the time your doctor starts talking about cataract surgery, you should qualify for coverage. Medicare typically covers cataract surgeries that doctors perform using traditional surgical techniques or lasers. 

There are two types of cataract surgery that Medicare specifically covers. These include extracapsular surgery, which removes the clouded lens completely and replaces it with an artificial lens, and phacoemulsification, which uses sound waves to break up the cloudy lens before replacing it with an artificial one.

In order for your cataract surgery to be eligible for coverage under Medicare, your vision must be 20/40 or worse, which in many states is the cutoff limit for driving without any restrictions. Your vision must also impact your activities of daily living by making it difficult to do things like drive, read, watch TV, work or perform other activities. Your doctor needs to document that your cataracts are affecting you this way before your surgery is approved and covered.

What Medicare Covers

As long as you meet the requirements, Medicare will cover the surgery and some other related expenses. It helps to talk to your doctor to understand the coverage better and to prepare for possible out-of-pocket expenses. Specifically, Medicare covers certain elements of the surgery but not others. Covered provisions include the removal of the cataract, implantation of the new artificial lens and a pair of prescription glasses or set of contact lenses after your surgery.

The different parts of Medicare also cover differing aspects of the surgery. If you need to be admitted to the hospital after your cataract surgery, Part A of your Medicare insurance covers that. Part B covers outpatient services, and because cataract surgery is typically an outpatient procedure, Part B will likely be what covers most of the procedure. 

What You'll Pay

Your ophthalmologist is the doctor who's in charge of performing this surgery. Medicare typically covers approved amounts under Medicare Part B. While this insurance usually pays for the standard artificial lenses, Medicare typically doesn't provide coverage for upgraded prescription lens implants. You can expect to pay 20% coinsurance plus your deductible if you haven't met it yet for the year. If you opt for specialized prescription lens implants, you'll likely pay 100% of the cost for the lenses themselves.

Generally, waiting to have cataract surgery won't accelerate damage to your eyes. If you're waiting to learn more about the elements of your surgery that Medicare will cover, try to remain calm. Waiting won't harm you or your eyes, so you can take your time and work with your doctor to make the right decision for your individual situation and financial needs.

Resource Links:

https://www.healthline.com/health/medicare/does-medicare-cover-cataract-surgery

https://www.aao.org/eye-health/diseases/what-are-cataracts

https://www.mayoclinic.org/tests-procedures/cataract-surgery/expert-answers/cataract-surgery/faq-20058200

https://www.medicare.gov/coverage/prosthetic-devices

https://www.medicare.gov/coverage/eye-exams-routine

https://sanantonioeyeinstitute.com/blog/how-do-i-know-when-i-qualify-for-cataract-surgery/

https://www.allaboutvision.com/conditions/faq-cataract-surgery-medicare.htm

https://eyewiki.aao.org/Driving_Restrictions_per_State

https://www.mayoclinic.org/tests-procedures/cataract-surgery/about/pac-20384765