Is Cataract Surgery Covered by Insurance?

Cataract surgery is typically covered, at least in part, by health insurance plans, including Medicare, Medicaid, and private plans. The surgery must be deemed “medically necessary” to be covered by insurance, meaning that the impaired visual function has reached a certain threshold and the cataracts are interfering with daily activities. However, the coverage varies by plan, and deductibles and copays often apply. Medicare Part B covers 80% of Medicare-approved costs for medically necessary cataract surgery, leaving the patient responsible for the remaining 20%.  If the patient has a supplement plan, this plan will almost always cover the remaining 20%.  Private insurance companies also cover cataract surgery, but the specific costs and coverage details depend on the individual’s insurance plan. Some plans may not cover all services related to cataract surgery, such as diagnostic exams and pre-surgery treatments. Additionally, many premium intraocular lenses (IOLs) are not covered by insurance and require an out-of-pocket cost. It’s important to speak to your insurance provider before the surgery to understand your plan benefits and out-of-pocket payments  It is not good for anyone to have a surprise bill.   Even if you have no insurance, you can generally negotiate a cash price from $4000-$5500 per eye depending on the surgeon, facility, and lens choice.  Contact us if you have questions!

While most health insurance companies cover cataract surgery, there are limits to the coverage. For example, some plans will cover basic intraocular lenses (IOLs) to replace the clouded ones, but if you choose newer versions, you will be required to pay for them. Medicare and private insurance typically cover traditional mono-focal lenses for cataract surgery, but premium upgrades  to advanced technology lenses, such as toric lenses and multifocal lenses, must be paid for out-of-pocket by the patient. Laser cataract surgery is generally not covered by insurance and technically a patient cannot be charged extra for this as technique variations do not change reimbursement.   Surgeons utilizing this technology offer additional services with the laser assisted technology and these requires out-of-pocket payment.

In summary, cataract surgery is generally covered by health insurance plans, including Medicare, Medicaid, and private plans, as a medically necessary procedure. However, the specific coverage details, including deductibles, copays, and coverage for advanced techniques and lens options, vary by individual insurance plans. It’s important to consult with your insurance provider to understand the coverage and any potential out-of-pocket expenses before undergoing cataract surgery.