Medicare Coverage for Cataract Surgery

Virtually all cataract surgeries are done in outpatient settings. Even if it is done at a hospital, it is usually done on an outpatient basis with no need to be admitted to the hospital to recover.

A cataract is an eye condition that causes the natural lens in your eye to become cloudy to the point that it obscures your vision. Cataract surgery involves removing the natural lens and replacing it with an artificial one.

Traditional procedures use a blade to remove the lens, while more modern cataract surgery uses a laser to make a precise incision to remove the natural lens.

Different parts of Medicare cover different costs related to traditional or laser-assisted cataract surgery. You will be responsible for certain out-of-pocket expenses.

Medicare supplemental insurance, also known as Medigap plans, may cover some of your share of the expenses.

The average Medicare beneficiary pays $361 for cataract surgery in ambulatory surgical centers and $573 for procedures in hospital outpatient departments, according to the U.S. Centers for Medicare & Medicaid Services.

There are several factors that can affect your cost for Medicare-covered cataract surgery. These can include the type of Medicare plan you have as well as where you have the surgery done.

Medicare’s own cost surveys found doctor fees are pretty consistent between the two, but facility fees can vary widely. This facility fee difference can affect your out-of-pocket costs.

The national average facility fee for hospital outpatient departments is $2,866, compared to $1,808 for ambulatory surgical centers. This affects how much Medicare covers, thus impacting your out-of-pocket expenses.

You should be aware that your surgery may require more than one doctor, and you may have to pay additional fees beyond the estimated average cost that Medicare reports.

Medicare Part B covers outpatient cataract surgery and medical costs associated with your operation such as doctor visits before and after the surgery. Most cataract surgeries are performed in outpatient settings.

Medicare covers 80% of the Medicare-approved costs for these medical services. You are responsible for the remaining 20%, plus your Part B deductible ($226 in 2023).

Medicare Part A will cover cataract surgery costs if you are admitted to a hospital where the surgery takes place.

This is extremely rare, since most cataract surgeries take place in outpatient settings.

If your procedure is done while you are an inpatient, you will need to pay 20% of the Medicare-approved cost of the surgery, plus the Part A deductible ($1,600 in 2023).

Medigap, sometimes called Medicare supplemental insurance, helps pay your out-of-pocket costs if you have Original Medicare.

You have to buy a Medigap plan through a Medicare-approved private insurer. You cannot buy a Medigap plan if you have Medicare Advantage.

Medigap plans vary, so you should ask your plan’s administrator what expenses your plan covers, such as deductibles and copayments for Original Medicare.

Medicare Advantage plans, sometimes called Medicare Part C, are sold by private insurers that contract with Medicare. These plans are required to provide the same coverage as Original Medicare, but they may provide additional benefits and coverage.

At a bare minimum, a Medicare Advantage plan will cover all the cataract surgery costs that Original Medicare covers. But you should check with your plan to find out what your benefits are and how much you may have to pay out-of-pocket for the surgery, since costs will vary from plan to plan.

You should also find out what additional cataract surgery benefits your plan may offer that you could take advantage of.

Medicare Part D prescription drug coverage can help you pay for the prescription drugs you will need following cataract surgery.

If you have Original Medicare, you’ll have to purchase a separate Part D prescription drug plan, but these plans are often included in a Medicare Advantage plan. You should check if a Part D plan is included before purchasing a Medicare Advantage plan.

Some medications related to your immediate surgery may be covered by Medicare Part B, but only if Medicare considers them to be medical, rather than prescription drug, expenses.

Medicare Part B will pay 80% of the Medicare-approved cost for one pair of glasses with standard frames or one set of contact lenses following each cataract surgery to implant an intraocular lens.

You have to pay the remaining 20% plus any additional cost for upgraded eyeglass frames.

Following cataract surgery, Medicare will only pay for glasses or contact lenses from a Medicare-enrolled supplier. Check to make sure the supplier is enrolled in Medicare.

Cataract surgery is one of only a few exceptions in which Medicare will pay for glasses or contact lenses.