There are many variables in the cost of cataract surgery: type of intraocular lens (IOL), type of preoperative testing (basic or basic plus refractive), geographic location (urban vs rural), and length of postoperative care.
According to AllAboutVision.com’s 2012 report, the average, basic cataract surgery in the US would cost roughly $3,429 per eye if you paid everything yourself. If you wanted an advanced technology lens which corrects astigmatism or presbyopia, expect to pay an additional $449 or $895 per eye.
But Isn’t Cataract Surgery Covered by Insurance?
Yes, for most people! Most people undergoing cataract surgery qualify for Medicare or commercial health insurance to “cover” the procedure. “So the whole procedure is covered.” Yes and No. The whole part of the procedure which is medically necessary is covered, but not any part of the procedure which is deemed not medically necessary such as screening tests, Refractions, Astigmatism Correction, Presbyopic Correction, LASIK or Excimer Laser surgery, Touchups, or extended postoperative care for a year (anything past the typical 90 days).
Take a basic single focus IOL for example. Medicare covers the whole cost of the part of the procedure which is medically necessary. This is because your natural prescription lens (cataract) is removed during the cataract surgery and a basic single focus IOL is implanted. This is medically necessary because your eye needs an artificial, prescription lens after the cataractous lens is removed in order to restore sight. Determining the prescription power of the basic IOL is a covered procedure as well. Advanced refractive testing (any type of testing to determine the refractive state of the eye), topography screenings, pupil screening, OCT screenings and other screening tests part of a refractive procedure are not a medically necessary set of tests, but may be recommended to achieve refractive results. The costs of any of these tests before cataract surgery should be very explicit and given to the patient. These refractive tests are not mandatory, but may be recommended to screen for issues which may impact great results with basic cataract surgery outcomes.
What about astigmatism correction? Same rules apply here. Remember that most commercial insurances and secondary insurance companies follow Medicare’s rules. Medicare usually determines that astigmatism correction is not medically necessary since this can be corrected with glasses. Most studies indicate that correcting astigmatism in the eye is better than correcting astigmatism in the glasses, but Medicare still sees this as non-medically necessary. Medicare will cover all of the medically necessary part of the cataract surgery including the cost of a basic IOL. If a Toric Astigmatism Correcting IOL is used or if a Limbal Relaxing Incision is used, Medicare and secondary insurances will not cover this part of the procedure because if is deemed non-medically necessary.
I get the picture. Probably a Multifocal or Accommodating IOL (Presbyopic IOL) is not covered, right? Yes and no. Remember, Medicare (secondary or commercial insurance companies, too) still covers a majority of the surgery; most of the surgical cost is the basic, medically necessary portion-this is covered. The portion that relates to advanced refractive preoperative testing, presbyopia correction, the presbyopic IOL, and any extended postoperative care (days 91-365) is not a covered portion.
This doesn’t make sense. What’s the deal? Insurance companies state:
- Over-the-counter Readers are cheap and provide you with vision to function
- If you need a prescription to see well at distance after the cataract surgery, even if you didn’t need one before the cataract surgery, you would still be responsible for this on your own
- vision correction (Refractive) such as Glasses, contacts or LASIK surgery are typically out of pocket costs.
I’m still a bit confused because all of my friends and family who had cataract surgery could see great and didn’t have to pay any extra. Everyone is different and some people achieve different results. Be certain to ask your eye surgeon’s billing coordinator about a detailed description and costs. Remember, there are 2 major costs: The surgeon’s fee and the facility’s fee, each having portions which are medically necessary and non-medically necessary (cosmetic). You get to choose if you want to have any of the non-medically necessary portions. Each of the medically-necessary portions will have associated copays and deductibles, while each of the non-medically necessary portions are out-of-pocket charges you are responsible for paying to the doctor and facility.
Standard Medicare and Health Insurance Coverage for Cataract Surgery
If you choose to have basic cataract surgery (no advanced preoperative refractive testing or astigmatism/presbyopia correction or extended postoperative care), then Medicare coverage is very easy to understand with respect to paying the surgeon and facility where the surgery is performed. Remember, most private or commercial health insurances tend to follow medicare’s rules on what is allowable or medically necessary.
Questions to Ask Your Insurance Provider:
- Is cataract surgery covered or medically necessary?
- Is astigmatism or presbyopia correction covered or medically necessary?
- Is Refractive or Refraction technology covered or medically necessary (such as refraction, topography, pupil analysis, wavefront analysis, angle kappa)?
- Are non-medically necessary screening tests covered?
- How much is the copay at the surgery center?
- How much is the copay for the surgeon?
- How much does insurance cover the non-medically necessary portion for the surgery center?
- How much does insurance cover the non-medically necessary portion for the surgeon?
- How much deductible do I need to meet?
- Is the cataract surgeon a preferred provider?
- Is the surgery center a preferred provider?
Credit: much of this article was paraphrased from AllAboutVision.com. For the whole article, read here: http://www.allaboutvision.com/conditions/cataract-surgery-cost.htm
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