Does Medicare Cover Cataract Surgery in Chicago, IL?

Cataract surgery is a common procedure for people of all ages to help restore vision loss due to cataracts. Does Medicare cover cataract surgery? Yes, it does. However, the extent of coverage depends on a patient's specific insurance plan.

Cataract surgery in Chicago can be expensive. Medicare, a government-funded health insurance program, can help cover the cost of the procedure for those who qualify.

In this blog, we'll discuss cataract surgery costs, how much Medicare covers, and how to select the best plan for maximum coverage.

How Much Does Medicare Pay for Cataract Surgery?

Is cataract surgery covered by Medicare? Yes, Original Medicare and Medicare Advantage provide coverage for cataract surgery. Original Medicare covers 80% of the cost of the surgery, leaving you responsible for the remaining 20%, which can either be paid out of pocket or with supplemental insurance like Medigap.

Many Medicare Advantage plans cover the total cost of cataract surgery; however, we recommend you confirm with your insurance company and review your specific policy before scheduling the procedure.

The cost of cataract surgery varies based on your location and the complexity of your cataracts. Using an ambulatory surgical center is about $1,789, of which Medicare covers $1,431, therefore you will have to pay $357.

Outpatient services at a hospital are around $2,829, with Medicare paying $2,263 leaving you to cover the remaining $565.

Please note: If you have Medicare Advantage, the cost will depend on your plan and the type of intraocular lens you need. Remember, you must choose a provider and facility in your plan's network to qualify for Medicare cataract coverage.

Medicare Advantage plans may also require a copayment, so be sure to get a full explanation of your policy benefits before scheduling an appointment. You can use Medicare's procedure price lookup tool to get a breakdown of the possible costs.

Navigating Medicare, and Cataract Surgery

Medicare is a federal program that provides basic health insurance for older adults and those with certain medical conditions.

A traditional Medicare plan without additional coverage helps avert potentially high medical bills. A cataract is a condition that can cause blindness if left untreated. Health insurers consider cataracts a significant medical problem and typically cover most of the medical costs related to them.

As such, Medicare coverage for cataracts typically covers the cost of cataract removal and replacement of the lenses. However, the amount you will pay and how the program works will depend on your specific Medicare coverage.

The main distinctions between having cataract surgery with Original Medicare (with or without a Medigap plan) and a Medicare Advantage plan are the out-of-pocket cost structure and the provider options.

With Original Medicare, you can have cataract surgery at any provider or facility that accepts Medicare. If you have a Medicare Advantage plan, you can only have the surgery done by an in-network provider and facility.

Original Medicare

Medicare Part A: This form of Medicare covers procedures that happen in a hospital. If you’re very sick or hurt and need treatment from an inpatient facility, your treatment is covered through this form of Medicare.

You can qualify for Medicare coverage for cataract surgery if the procedure happens inside an inpatient facility and you need aftercare treatment in that location; your costs would be covered through Medicare Part A.

Medicare Supplement (Medigap) Plans

Medicare Part B: If you receive outpatient care at a clinic or surgery center, Medicare Part B can help cover the cost of those therapies and treatments. Part B can also pay for corrective lenses if your vision doesn't improve after surgery. You will need to pay a deductible before accessing Part B services, and you may need to pay copayments as well.

Medicare Advantage (MA) Plans

Medicare Part C: Medicare is a federal program available across the United States. For those who opt-in, some private insurance companies offer a type of Medicare called Medicare Advantage. It acts as an additional layer of insurance coverage in addition to the existing Medicare plan.

The coverage provided by a Medicare Advantage plan can differ significantly from one insurance company to the next, as each company has something unique to offer its customers. In some cases, states may also restrict what services companies can and cannot provide. If you have opted for a Medicare Advantage plan, you may receive additional benefits regarding the extent of cataract surgery covered by Medicare.

Medicare Drug Plan

Medicare Part D: Medicare Part D can help cover the sometimes hefty cost of prescription medications such as pain relief, eye drops, or other post-surgery treatments.

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How Much Does Cataract Surgery Cost Without Insurance?

According to Medicare.gov, cataract surgery at an ambulatory surgical center costs around $1,789. This includes $750 for doctor fees and $1,039 for facility fees. Alternatively, having the same surgery done in a hospital's outpatient department will run $2,829, with $750 in doctor fees and $2,079 in facility fees.

The cost of cataract surgery with Medicare Advantage plans will depend on your provider and the type of intraocular lens required (please note: our numbers are estimates). We advise speaking to a customer service representative to learn what you can expect to pay before proceeding.

How Much Does Cataract Surgery Cost with Medicare?

Your cataract surgery cost with Medicare will only cost 20% or less of the total cataract surgery bill. The surgery may even be free if you have a plan with a $0 outpatient copayment.

On average, those with Original Medicare only pay about $200 to $800 out of pocket per cataract procedure.

How Much Does Surgery Cost?

The cost of surgery depends on your procedure: LAL, Toric IOL, and Full Focus Vision Correction will not be identically priced. The average cost of cataract surgery is $3,500 per eye, reaching as high as $7,000!

If your case requires more complex care, the cost may be higher or lower than the estimated amount, but Medicare typically covers 80%. For example, Medicare would pay $2063 for outpatient treatment, and you would have to pay the remaining $515.

Does the Surgical Site Matter?

Yes, the surgical site will matter regarding cataract fees, which vary significantly depending on the facility and the type of surgery. Some facilities may charge more due to their reputation or specialized equipment, while others may charge less due to location or lower overhead costs.

The fees may also be affected by the complexity of the procedure and the type of anesthesia used. Depending on the surgery location, Medicare cataract surgery coverage may only cover a portion of the fees.

Are There Other Fees?

Yes, there are often post-op fees. Medicare will cover one pair of glasses after the surgery, but other items related to the treatment, such as updated frames, contact lenses, or eye drops, will not be covered. Before surgery, it is essential to speak to your healthcare provider to understand what is and is not covered by your plan to avoid unexpected costs.

Medicare Cataract Surgery Coverage Exclusions

Not all hospitals, clinics, and outpatient surgery centers accept Medicare payment plans. You'll have to pay the full fee if you choose a location that doesn't accept your plan.

Basic medicare also doesn't pay for follow-up appointments. If your doctor wishes to monitor your eye health to ensure you're healing appropriately, you'll need a Medicare Advantage plan to cover these costs.

How to Apply for Medicare Plans that Cover Cataract Surgery

During Medicare annual enrollment (October 15 to December 7), you can choose a Medicare Advantage plan that best suits you. If you're anticipating cataract surgery, you should check which plans offer higher coverage - even if that means paying a higher monthly premium. Additionally, the annual enrollment period is the best time to purchase a Medigap plan. Schedule a consultation and The Kraff Eye Institute help you to find out more details about it.