Cataracts Are Common Among Seniors: Does Medicare Cover Cataract Surgery?
Over 24 Million Americans have cataracts–and worse, the risk of cataracts increases each decade of life, starting around age 40. Statistically, as many as 50 percent of Americans over 75 will be diagnosed with cataracts, and by 80, that number has grown as large as 70 percent.
The good news is, Medicare does cover cataract surgery!
What Are Cataracts?
Before we discuss the Medicare requirements for covered cataract surgery, let’s first examine what cataracts are. Most simply, a cataract is a cloudy area in the lens of your eye. At first, you may not notice that you have a cataract. But over time, cataracts can make your vision blurry, hazy, or less colorful. You may have trouble reading or doing other everyday activities.
What Are the Types of Cataracts?
There are a few different types of cataracts. Most cataracts are age-related — they happen because of regular changes in your eyes as you get older. But you can get cataracts for other reasons — for example, after an eye injury or after surgery for another eye problem (like glaucoma).
What’s the Treatment for Cataracts?
Surgery is the only way to get rid of a cataract, but you may not need to get surgery right away. This is a crucial distinction when it comes to Medicare requirements for covering cataract surgery, as we’ll examine below.
During cataract surgery, the doctor removes the clouded lens and replaces it with a new, artificial lens (also called an intraocular lens, or IOL). This surgery is very safe, and 9 out of 10 people who get it can see better afterward.
Am I at Risk for Cataracts?
Your risk for cataracts goes up as you get older. You’re also at higher risk if you:
- Have specific health problems, like diabetes
- Drink too much alcohol
- Have a family history of cataracts
- Have had an eye injury, eye surgery, or radiation treatment on your upper body
- Have spent a lot of time in the sun
- Take steroids (medicines used to treat a variety of health problems, like arthritis and rashes)
If you’re worried that you might be at risk for cataracts, talk with your doctor. Ask if there is anything you can do to lower your risk.
What Does Medicare Require to Cover Cataract Surgery?
For Medicare to cover cataract surgery or any other medical procedure, it must be “medically necessary.” Your doctor will probably suggest cataract surgery if you have vision loss that gets in the way of everyday activities like reading, driving, or watching TV.
Sometimes, your doctor might recommend cataract surgery even if your cataracts aren’t the leading cause of your vision problems. For example, the doctor might remove cataracts so they can see the back of your eye. If you have another eye condition, like diabetic retinopathy or age-related macular degeneration (AMD), your doctor will need to see the back of your eye to help you manage it.
While Medicare requires that cataract surgery be medically necessary, that’s not the same as being urgent. Cataracts are not a medical emergency, and you don’t need to rush to have surgery to remove them. Ask your doctor about the risks and benefits of cataract surgery to decide if it’s is right for you.
How do I Prepare for Cataract Surgery?
At your doctor’s office before the day of the surgery, your doctor will do some tests to measure the size and shape of your eye. You may need to use some special eye drops before the surgery, and your doctor may tell you not to eat anything the night before your surgery.
You won’t be able to drive yourself home after the surgery, and you’ll need a friend or family member to make sure you get home safely — so be sure to bring someone with you.
If you have cataracts in both eyes, you’ll need to have surgery on each eye at a separate time, usually about four weeks apart.
What Happens During Cataract Surgery?
The doctor will remove the cloudy lens from your eye during surgery and replace it with an artificial lens (called an intraocular lens). The surgery lasts about 1 hour and is almost painless.
Usually, you will be awake during cataract surgery. You might notice lights or motion, but you won’t be able to see what your doctor is doing.
When you get this surgery, your doctor will:
- Put numbing drops into your eye to keep you from feeling anything
- Use tiny tools to cut into your eye, break up the lens, and take it out
- Place the new artificial lens in your eye
Right after surgery, you will need to rest in a recovery area outside the operating room for a little while. Before you go home, the medical team will check to make sure you don’t have any problems with your eye.
What Happens After Cataract Surgery?
Your doctor will explain how to protect your eye after cataract surgery. They will give you eye drops to help your eye heal, and you may need to wear a special eye shield or glasses. You may need to avoid some activities for a few weeks, like touching your eye, bending over, or lifting heavy things.
Your eye may feel a bit itchy or uncomfortable and sensitive to light and touch. After 1 or 2 days, your eye should feel better.
Call your doctor right away if you notice any of these problems after surgery:
- Vision loss
- Bad pain that won’t go away even if you take medicine for it
- Very red eyes
- Flashes of light or a lot of small dark spots or squiggly lines that float across your vision (floaters)
Most people are entirely healed eight weeks after their surgery. Your doctor will schedule checkups to make sure your eye is healing correctly.
Will My Vision be Normal after Cataract Surgery?
About 9 out of 10 people who get cataract surgery see better afterward, but your vision might be blurry at first while your eye recovers.
Some people notice that colors seem brighter after cataract surgery. The brighter color is because the artificial lens is clear, while your natural lens had a yellow or brown tint from the cataract.
Once your eye is completely healed, you might need a new prescription for glasses or contact lenses to see clearly.
What Are the Risks of Cataract Surgery?
Cataract surgery is one of the most common, safe, and effective types of surgery done in the United States. But like any surgery, there are risks, including:
- Swelling, bleeding, or infections
- Vision loss or double vision
- Unusual changes in eye pressure
- Retinal detachment
- Secondary cataract (posterior capsule opacity)
Your doctor can treat these problems if they catch them early. Be sure to go to all of your checkups, and call your doctor if you notice anything wrong with your eyes or vision.
Is Cataract Surgery Covered Under Medicare Part B?
Cataract surgery is an outpatient procedure. You do not need to be admitted to the hospital usually, and you probably will not stay overnight. So cataract surgery falls under Medicare Part B. Medicare covers cataract surgery, and pays for glasses and contact lenses after the surgery, if necessary.
What Does Medicare Pay for in Cataract Surgery?
Because it is outpatient surgery under Part B, Medicare will pay 80% of the cost of your cataract surgery. You will be responsible for the 20% coinsurance. If you go to the Procedure Price Lookup on the Medicare website, you can see the approximate amount Medicare covers for cataract surgery and how much you will need to pay out of your pocket you pay for the procedure.
If you have a Medicare Supplement or Medigap policy, the policy will pay some or all of the coinsurance after the Part B deductible is met depending on your type of Medigap policy, (e.g., Plan G, Plan N, etc.).
With Medicare Advantage, the Evidence of Coverage lists cataract surgery and other outpatient procedures in the booklet for each plan with the copay. In the Benefit Highlights in the enrollment handbook for each MA plan, outpatient procedures are listed. This can help you to understand how much Medicare Advantage will cover for your cataract surgery and what you will pay.
How Much Should I Expect to Pay for Cataract Surgery If I Have Medicare?
In the Omaha-Lincoln-Council Bluffs Metro area, the cost from a Medicare Advantage plan for a beneficiary ranges from $250-$400 per eye, assuming you get the most common procedure.
According to the Procedure Price Lookup tool, without a Medicare Supplement and only Medicare Part B, the cost of your cataract surgery would be around $316 for an Ambulatory Surgery Center and $524 for a Hospital Outpatient Department. There are nine possible types of cataract surgery for which Medicare pays. Medicare lists each procedure with nine different billing codes. There are even more options that are not listed.
Does Medicare Cover Cataract Surgery and Implants?
Medicare covers the total cataract procedure: doctor services, facility services, and medical devices (lens, drops, suture, etc.). Medicare authorizes the use of standard lens prostheses.
If the patient wants something more than Medicare’s standard lens, there will likely be an additional cost. The doctor’s billing office will explain and is required to have you sign off on, any non-Medicare additional costs of your cataract surgery before performing the procedure.
Clients Let Me Know Medicare Covers Cataract Surgery
Many clients will call to find out whether Medicare covers cataract surgery and how much they should expect to pay based on their plan. They’ll also call afterward to tell me how it all went.
Cataract surgery is a topic that I get called about often. It amazes them how little cataract surgery costs for both those on Medicare Advantage or a Medigap policy.
If you would like to know more about your options for coverage under a Medicare Advantage plan or a Medigap plan, contact OmahaInsuranceSolutions.com 402-614-3389 today and speak with a licensed agent!