Cataracts can significantly impact a person’s quality of life. Making it difficult to perform daily tasks and potentially leading to blindness if left untreated. Cataracts or cataract surgery affect more than 50% of adults over the age of 80. Also, the cost of the procedure can often be a significant financial burden. It’s important to understand how Medicare Advantage plans pay for cataract surgery.
Does Medicare Advantage cover cataract surgery?
Yes, Medicare Advantage plans cover cataract surgery that removes a cataract and replaces it with a conventional intraocular lens. Cataract surgery is a common and medically necessary procedure covered by most Medicare Advantage plans, also in Original Medicare.
The benefit of Medicare Advantage plans is offer additional coverage beyond Original Medicare (Part A and Part B). It means that you have additional benefits or coverage for cataract surgery that you wouldn’t have with Original Medicare alone.
However, according to Herrin, not all physicians, hospitals, and surgery centers are contracted with these plans. So, it’s really important to double-check with your insurance company before scheduling your procedure. On the other hand, Herrin says that almost every physician and hospital is contracted with Original Medicare.
Wesley Evans
Coverage for cataract surgery under Medicare Advantage
Here are some general aspects of cataract surgery that Medicare Advantage plans may cover:
- Surgical procedure: This typically includes the cost of the surgery itself, including the surgeon’s fee, anesthesia, and use of the operating room.
- Pre-operative care: Visits with the surgeon or medical professionals to discuss the procedure, as well as any necessary tests or imaging scans.
- Post-operative care: Follow-up visits with the surgeon or other medical professionals to monitor healing and ensure that there are no complications.
- Equipment and supplies: This may include the cost of any equipment or supplies needed during the surgery or recovery period, such as prescription medications.
- Hospitalization: If the surgery requires a hospital stay, your Medicare Advantage plan may cover the cost of your hospital stay. Your Medicare Advantage plan may also cover any additional medical services or treatments that are necessary during your hospitalization.
It’s important to keep in mind that not all Medicare Advantage plans are the same. The specific details of your coverage will depend on the plan that you have. Additionally, some plans may require you to use certain hospitals or doctors to receive coverage. So it’s important to check with your specific plan to understand what is covered and what is not.
Factors that may affect coverage
Here are the main factors that may affect your Medicare Advantage coverage for cataract surgery:
- Pre-existing conditions: If you have a pre-existing eye or vision condition, your coverage may be different than if you didn’t have any pre-existing conditions. Review your plan’s coverage and any pre-authorization requirements to understand your specific coverage.
- Location of the surgery: The cost of cataract surgery can vary depending on where you live. Your Medicare Advantage plan may have different coverage options based on the location of the surgery. So review your plan’s coverage and any network requirements.
- In-network vs. out-of-network providers: Using an in-network provider may result in lower out-of-pocket costs than using an out-of-network provider. Some Medicare Advantage plans may only cover cataract surgery if it’s performed by an in-network provider. Review your plan’s coverage and any network requirements to understand your coverage options.
Factors that may affect coverage
Several factors can impact the coverage of cataract surgery under Medicare Advantage plans. It’s important to understand these factors in order to know what your plan covers and what your out-of-pocket costs might be. Here are the main factors that may affect your Medicare Advantage coverage for cataract surgery:
- Pre-existing conditions: If you have a pre-existing eye condition, your coverage may be different than if you didn’t have any pre-existing conditions. Review your plan’s coverage and any pre-authorization requirements to understand your specific coverage.
- Location of the surgery: The cost of cataract surgery can vary depending on where you live. Your Medicare Advantage plan may have different coverage options based on the location of the surgery, so review your plan’s coverage and any network requirements.
- In-network vs. out-of-network providers: Using an in-network provider may result in lower out-of-pocket costs than using an out-of-network provider. Some Medicare Advantage plans may only cover cataract surgery if it’s performed by an in-network provider. Review your plan’s coverage and any network requirements to understand your coverage options.
How much does cataract surgery cost with Medicare Advantage?
It’s important to understand that Medicare Advantage plans may have different out-of-pocket costs for cataract surgery than Original Medicare. While Original Medicare typically covers 80% of the cost of cataract surgery, you may be responsible for the remaining 20% out of pocket.
- Co-pays and deductibles: Medicare Advantage plans often require co-pays or deductibles for medical procedures, including cataract surgery. The amount of the co-pay or deductible will depend on the specific plan and policy, but it can range from a few hundred to a few thousand dollars.
- In-network vs. out-of-network providers: If you choose to have cataract surgery with an out-of-network provider, your out-of-pocket costs may be higher. In-network providers may have lower negotiated rates with Medicare Advantage plans, which can result in lower costs for the patient.
- Plan coverage: Some Medicare Advantage plans may cover the full cost of cataract surgery, while others may only cover a portion of the cost. It’s important to review your plan’s coverage to understand what your out-of-pocket costs may be.
Medicare.gov states that the cost of cataract surgery at an ambulatory surgical center is approximately $1,789, with doctor fees amounting to $750 and facility fees totaling $1,039. Medicare pays $1,431, leaving the patient with $357 to pay. Ambulatory surgical centers cater to patients who do not require more than 24 hours of care.
In contrast, if cataract surgery is performed at a hospital’s outpatient department, it costs $2,829, with doctor fees amounting to $750 and facility fees totaling $2,079. Medicare pays $2,263 of this amount, which means the patient has to pay $565. These estimates may vary based on the location and the complexity of cataracts.
The cost of cataract surgery with MA depends on the specific plan and the type of intraocular lens required.
Frequently Asked Questions
Medicare Advantage plans will generally cover standard mono-focal lenses for cataract surgery. However, if you choose a more advanced lens, such as a multifocal or accommodating lens, you may be responsible for additional costs.
Cataract surgery is typically covered by Medicare Advantage plans as a medically necessary procedure, so there are no restrictions on when you can have it done.
Most Medicare Advantage plans allow you to choose your own surgeon, but you may need to check with your plan to make sure the surgeon is within the plan’s network.
