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What is cataract surgery and is it covered by Medicare?

If your eye doctor tells you that you have cataracts in one or both eyes and recommends surgery to remove them, don’t despair.

When you can’t see as well as before, one reason may be that cataracts have developed in one or both eyes. Cataracts are the clouding of the eye’s natural lens. Cataract surgery removes the cloudy lens and can replace the lens at the time of surgery with different types of lenses, and by age 80, more than half of all Americans have cataracts or have had cataract surgery, according to the National Eye Institute.

When cataracts interfere with your daily life (driving, reading, working with a desktop or laptop computer, needlework, or playing sports), it may be time to consider cataract surgery.

Decisions about cataract surgery begin with an examination and conversation with your doctor. After that, “it’s a personal decision,” said Vicente Diaz, assistant professor of clinical ophthalmology at Yale School of Medicine and chief of ophthalmology at Bridgeport Hospital.

Eye surgeons remind patients that while cataract surgery is a common procedure, it is considered elective, meaning a decision that must be made by each individual. Your eye doctor can certainly tell you when is the optimal time for you to have a cataract removed.

“Discuss with the doctor what your life is like, how you spend your time, your activities and what is important to you,” Diaz said. “Your doctor can help you come up with a plan” that’s best for you.

Removing the cataract and inserting a new lens can restore or improve your vision.

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If you haven’t had your cataracts removed, consider an extra bonus: Research shows that cataract surgery has been associated with about a 30% lower risk of developing dementia among adults age 65 and older, according to one study published in JAMA Internal Medicine in December. , 2021 in the paper, “Association between cataract extraction and the development of dementia.”

What costs will Medicare cover?

Original Medicare covers 80% of the approved cost of cataract surgery that a doctor completes using traditional surgical techniques or lasers, according to the Centers for Medicare and Medicaid Services. The patient is responsible for the remaining 20%, after the Medicare deductible ($226 for Part B) has been met. Specifically, Original Medicare covers the procedure used to remove the cataract that the doctor deems medically necessary, pays for medical services and supplies needed to insert a conventional intraocular lens (IOL) during cataract surgery, as well as for medical services and related care after surgery.

Also, Original Medicare pays for one pair of glasses after every cataract surgery that includes the insertion of a conventional IOL, also known as a monofocal IOL, according to the Centers for Medicare and Medicaid.

Just be aware that the type of lens recommended for your eyes can affect the cost of the procedure and how much will be covered by Medicare or other insurance. Lens options include monofocal lenses, multifocal lenses, monovision where one eye is set for near vision and the other for distance vision, adjustable light lenses, toric lenses, and extended depth of focus lenses. Except for monofocal lenses, most other lenses are not covered by Original Medicare or other insurance you may have. If imaging is needed to insert lenses other than monofocals, Medicare does not cover this cost.

Where the procedure is performed determines how Medicare covers the cost. Original Medicare covers the cost of a surgery center or other facility charges or fees, or a procedure in a doctor’s office, an amount according to the Physician’s Fee Schedule (PFS) which represents both the costs of using the office space and the doctor’s work.

If the procedure is performed in a hospital outpatient setting, it is paid 80% in two parts under the Outpatient Prospective Payment System (OPPS) and separately for the physician under the PFS, according to the Centers for Medicare and Medicaid. The patient pays the remaining 20% ​​or, if they have other insurance, such as a Medicare supplement plan or a gap plan, it may be paid by that insurer. If you have a Medicare Advantage plan, check with your insurance company before scheduling your surgery to determine what will be covered and what the out-of-pocket costs will be.

Medicare pays for conventional or monofocal lenses as part of the fitting fee.

Monofocal lenses are covered, including monovision in which the surgeon inserts two monofocal lenses of different powers, said Yvonne Wang, an ophthalmologist at Yale School of Medicine who specializes in cataract and corneal surgery. “However, multifocal, light adjustable and toric lenses are never covered and the payer will have to pay out of pocket. The cost of these lenses is set by the University or the practice,” he said.

However, according to the Centers for Medicare and Medicaid, “Medicare coverage and payment for cataract surgery is the same regardless of whether the surgery is performed using conventional surgical techniques or a bladeless computer-controlled laser. With either method, Medicare will cover and pay for cataract removal and the insertion of a conventional intraocular lens, also called a monofocal lens.

The total cost of cataract surgery depends on the type of insurance you have, Wang said. “Sometimes we need to get pre-authorizations from private insurance.”

She advises patients to contact their insurance provider. Check before you schedule surgery, especially if the out-of-pocket cost is an important consideration for you.

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