Question: I need to have cataract surgery. Does Medicare help pay for this surgery?

Answer: Original Medicare is a health insurance product. This means that all of your coverage must be based on a medical problem or diagnoses. Most of us develop age related vision problems. Medicare will cover the appointment to see an eye doctor, like it would for any specialists. Medicare Part B covers the exam. Medicare requires that you see a participating ophthalmologist. Sometimes an optometrist is also included in your coverage, depending on your state. In making your appointment, explain that you have Medicare and ask if they participate with Medicare and if Medicare will cover this appointment.

Medicare will cover the eye exam for those with a medical diagnosis, and also injuries and illness of the eye. Medicare sometimes covers your corrective lenses in limited situations – if you have glaucoma, cataracts, or macular degeneration for example.

Medicare covers Cataract Surgery. After you have cataract surgery, your vision will have changed significantly, sometimes to the point of not needing glasses at all. If you do still need corrective lenses after your surgery, Medicare will pay for the lens on the eye that had surgery. Medicare does NOT pay for the frames. Remember that this benefit is paid under Medicare Part B, so the usual deductible ($257) and co-pays (80/20) apply.

If you have a Medicare Advantage plan (like an HMO, PPO, and PFFS plan) your cataract surgery will also be covered but you will likely have a copay for the doctor’s appointment and the surgery itself. This copay is usually in the $200 to $400 window, but that also depends on your plan. Many Medicare Advantage Plans give you additional coverage for glasses, often in the $75 to $350 range. Remember these Medicare Advantage Plans must give you at least the minimum that Medicare gives you, but they can give you MORE coverage. When making your appointment for your surgery, be sure to inform the office of your Medicare Advantage Plan’s company and the name of your plan – check your insurance card for this information. Coverage and participation in these plans will be different for each office.

With a Medicare Advantage plan, be sure to call the plan prior to getting your glasses. They may restrict who you may go to based on your Provider Network, and what type of glasses/ frame they will reimburse you for.

Getting back to the Cataract Surgery, the copay and cost structures cover the surgery itself. However, many individuals opt for a higher-end surgery, which would include additional lens implants that correct their vision. These higher-end surgeries are usually not covered by Medicare and Medicare Advantage Plans. So many individuals run into about $1500 to $3000 per eye in additional fees. That is common and appropriate if you have chosen that upgraded surgery and lens implant.

Many employee/ retiree plans offer an additional insurance plan for vision. It is also possible to purchase additional vision coverage (a common carrier goes by the name VSP). These insurance products are usually relatively low cost and require you go to participating providers. As an enrollee, you pay an additional premium for that kind of vision plan, but if you want to have coverage for that routine (annual) vision exam and possibly help pay for your glasses, this may be a product you would like to purchase. These plans are usually cost effective as long as you go to a participating provider and purchase glasses/ contacts that are included in the coverage of the plan.

There are also many different procedures and products that are available with regard to vision. Some of these are covered by Medicare and some are not. The corrective laser surgery that I talked about earlier is one of these situations. Be sure to talk about your Insurance coverage before you consent or decide on this procedure. You should not assume that any procedure is covered by your insurance plan. Ask about insurance coverage first, then schedule.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.