Does Medicare advantage cover cataract surgery?

Cataracts and cataract surgery are extremely common (over half of people over 80 either have cataracts or have had cataract surgery). The thought of having to pay for cataract surgery out-of-pocket can be overwhelming.

So, does Medicare Advantage cover cataract surgery? What will your out-of-pocket expenses be after Medicare covers their share? We’ll answer these questions below.

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Does Medicare Advantage cover cataract surgery?

So, does Medicare cover cataract surgery? Which parts of Medicare cover cataract surgery?

Medicare Part B covers cataract surgery as long as the surgery is completed using either traditional methods or lasers. Since Medicare Advantage plans have to be the same or better than original Medicare, these plans will cover the cataract surgery as well.

Medicare covers what is called an intraocular lens implant, which is a small disk that is implanted after the removal of cataracts to help with focusing your vision. However, Medicare will only cover the basic implant rather than the advanced ones.

Does Medicare Advantage cover eyeglasses and contact lenses?

After your cataract surgery, Medicare will cover one pair of eyeglasses or contact lenses. If you choose eyeglasses, you will have specific frames you can choose from. If you choose to upgrade to different frames, your out-of-pocket expenses will increase.

How much does cataract surgery cost with Medicare?

How can you know what your costs will be before cataract surgery? What other factors may affect how much you pay?

After your premiums and health care deductible, Medicaid will generally charge a 20 percent coinsurance. This means you will have to pay 20 percent of cataract surgery costs out-of-pocket.

What is the cost with Medicare?  According to Medicare.gov, an estimated total cost of cataract surgery performed in a surgical center is $1,777. Medicare would pay $1,422, while you would need to pay $355. In a hospital, the estimated total cost is $2,786. Medicare would pay $2,229, and you would pay $557.

The cost of your surgery may vary due to multiple factors, including your Medicare plan, the specifics regarding your surgical needs, the facility and healthcare provider, and potential complications (either during surgery or due to other disorders).

How much does cataract surgery cost with Medicare?

How can you know what your costs will be before cataract surgery? What other factors may affect how much you pay?

After your premiums and health care deductible, Medicaid will generally charge a 20 percent coinsurance. This means you will have to pay 20 percent of cataract surgery costs out-of-pocket.

What is the cost with Medicare?  According to Medicare.gov, an estimated total cost of cataract surgery performed in a surgical center is $1,777. Medicare would pay $1,422, while you would need to pay $355. In a hospital, the estimated total cost is $2,786. Medicare would pay $2,229, and you would pay $557.

The cost of your surgery may vary due to multiple factors, including your Medicare plan, the specifics regarding your surgical needs, the facility and healthcare provider, and potential complications (either during surgery or due to other disorders).

 Case Studies: Exploring Medicare Advantage Coverage for Cataract Surgery Shedding Light on Coverage, Requirements, and Outcomes

Case Study 1: John’s Experience With Medicare Advantage Coverage for Cataract Surgery

John is a 68-year-old Medicare Advantage beneficiary who has been experiencing blurry vision due to cataracts. He is considering cataract surgery to improve his vision but is unsure whether his Medicare Advantage plan will cover the procedure.

John contacts his Medicare Advantage plan’s customer service to inquire about coverage for cataract surgery. The representative informs him that cataract surgery is indeed covered under his plan, but certain conditions and requirements must be met. The representative explains that John needs to obtain a referral from his primary care physician and have his cataract condition evaluated by an ophthalmologist within the plan’s network.

Medicare Advantage plans can cover cataract surgery, but beneficiaries should be aware of the specific requirements and conditions set by their plan. It is essential to follow the proper procedure, including obtaining referrals and seeking services within the plan’s network, to ensure coverage.

Case Study 2: Lisa’s Encounter With Limited Coverage for Cataract Surgery under Medicare Advantage

Lisa, a 72-year-old Medicare Advantage enrollee, is experiencing significant vision impairment due to cataracts. She contacts her plan’s customer service to inquire about coverage for cataract surgery, hoping for full coverage.

The customer service representative informs Lisa that cataract surgery is covered under her Medicare Advantage plan. However, the representative explains that the plan has a coinsurance requirement for surgical procedures, which means Lisa will be responsible for a portion of the cost. Additionally, the plan’s network includes specific ophthalmologists, and Lisa must choose one of them for her surgery. (For more information, read our “Best Ophthalmologists That Will Accept Medicare“)

Lisa proceeds with the cataract surgery and chooses an ophthalmologist within her plan’s network. After the procedure, she receives a bill for the coinsurance portion of the surgery, which amounts to a few hundred dollars. Although Lisa is pleased with the outcome of the surgery, she is disappointed to discover that she had to pay a portion of the cost out of pocket.

Medicare Advantage plans may cover cataract surgery but can still impose coinsurance or other cost-sharing requirements. Beneficiaries should carefully review their plan’s coverage details, including any out-of-pocket expenses they may incur, to avoid unexpected costs.

Case Study 3: Mark’s Medicare Advantage Plan Denies Coverage for Cataract Surgery

Mark, a 65-year-old Medicare Advantage policyholder, is diagnosed with cataracts and is considering surgical treatment. He contacts his plan’s customer service to inquire about coverage for cataract surgery.

The customer service representative informs Mark that cataract surgery is not covered under his Medicare Advantage plan. Mark is surprised and asks for further clarification. The representative explains that his plan considers cataract surgery to be an elective procedure and therefore does not provide coverage for it.

Disappointed with the denial of coverage, Mark explores other options. He consults his primary care physician, who advises him to consider switching to Original Medicare, as it typically covers cataract surgery. Mark decides to disenroll from his Medicare Advantage plan and switches to Original Medicare to ensure coverage for his cataract surgery.

Medicare Advantage plans can vary in their coverage offerings, and some may consider cataract surgery to be an elective procedure rather than a medical one.

Conclusion

If you have a Medicare Advantage plan, your insurance provider will cover a basic cataract surgery with lens implants and one pair of eyeglasses or contact lenses.

After your premiums and deductible, you will need to pay a 20 percent coinsurance. The estimated cost for this out-of-pocket expense ranges from $355 to $557, depending on your Medicare plan, your surgical needs, the facility and doctor, and any potential complications. A Medigap plan may help cover some of these expenses.

You should contact your Medicare Advantage policyholder to get details about their cataract surgery and other vision coverage options.

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