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If your eye doctor tells you have cataracts in one or both eyes, and he recommends surgery to remove them, don’t despair.
When you cannot see as well as you could before, one reason can be that cataracts have developed in one or both eyes. Cataracts are the clouding of the natural lens in the eye. Cataract surgery removes the clouded lens and can replace the lens at the time of surgery with different types of lenses, and by 80, more than half of all Americans either have a cataract or have had cataract surgery, according to the National Eye Institute.
When cataracts interfere with your daily life – driving, reading, working at a desktop or laptop computer, doing needlepoint or playing sports – it may be time to consider cataract surgery.
Decisions about cataract surgery start 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, that is, a decision each individual has to make. Certainly, your ophthalmologist can guide you as to 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’s important to you,” said Diaz. “The doctor can help you come up with a plan” that is best for you.
Removal of the cataract and inserting a new lens can restore or improve your vision.
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If you’re wavering on having your cataracts removed, consider an additional advantage: Research shows that cataract surgery has been associated with approximately 30% lower risk of developing dementia among adults 65 and older, according to a study published in JAMA Internal Medicine in December, 2021 in the paper, “Association Between Cataract Extraction and Development of Dementia.”
What costs will Medicare cover?
Original Medicare covers 80% of the approved cost of cataract surgery a physician completes using traditional surgical techniques or with lasers, according to the Centers for Medicare and Medicaid Services. The patient is responsible for the remaining 20%, once the Medicare deductible — $226 for Part B — has been met. Specifically, original Medicare covers the procedure used to remove the cataract considered medically necessary by the physician, pays physician services and supplies required to insert a conventional intraocular lens (IOL) during cataract surgery as well as for physician services and related care after surgery.
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In addition, original Medicare pays for one pair of eyeglasses after each cataract surgery that includes the insertion of a conventional, 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 one for distance vision, light adjustable 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 monofocal ones, Medicare does not cover that cost.
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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 physician’s office one amount under the Physician Fee Schedule (PFS) that represents both the costs of utilizing the office space and the physician’s work.
If the procedure takes place in a hospital outpatient department it is paid at 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 supplemental Medicare plan or gap plan, it may be paid by that insurer. If you have a Medicare Advantage plan, check with your insurance company before you schedule surgery to determine what will be covered and what will be out-of-pocket expenses.
Medicare pays for conventional or monofocal lenses as part of the facility fee.
Monofocal lenses are covered, which includes monovision in which the surgeon inserts two monofocal lenses of different powers, said Yvonne Wang, a Yale School of Medicine ophthalmologist who specializes in cataract and corneal surgery. “However multifocal, light adjustable lenses and toric lenses are never covered and the payer will have to pay out of pocket. The cost of those lenses is set by the University or practice,” she said.
Yet, according to the Centers for Medicare and Medicaid, “Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is performed using conventional surgical techniques or a bladeless, computer-controlled laser. Under either method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens,” also called a monofocal lens.
The total cost of cataract surgery depends on the kind of insurance you have, said Wang. “Sometimes we do need to get prior authorizations from private insurances.”
She advises patients to reach out to their insurance provider. Check before you schedule surgery, especially if the out-of-pocket cost you will pay is a major consideration for you.
