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Cataracts affect millions of Americans. Fortunately, most Medicare plans provide coverage for medically necessary procedures, such as cataract surgery.
Paying for cataract surgery can be complicated. Unfortunately, Medigap cannot be used to cover copays, deductibles, or premiums associated with any Medicare Advantage Plans. Medigap can only be used with Original Medicare.
Cataract surgery costs thousands of dollars, so vision coverage is often needed to make the surgery affordable for most people. Some out-of-pocket expenses will remain, but your Medicare plan can help to cover the majority of the costs.
Coverage for Cataract Surgery
While most Medicare plans do not provide vision coverage unless it is medically necessary, cataract surgery is often covered. Original, Part A, and Part B Medicare plans do not cover routine eye exams, but certain preventative and diagnostic eye exams are covered.
Whether you have an MA Plan or a different Medicare plan, once cataract surgery has been determined to be medically necessary for you, cataract surgery is covered. Exact coverage varies by plan, but you can expect some version of the following coverage related to cataract surgery:
- Coverage of surgeon, facility, and anesthesia fees
- Responsibility to pay your Medicare deductible or 20 percent of the Medicare-approved amount once you have met your deductible
- Coverage of follow-up care
- Coverage of inpatient fees
- Coverage for lenses and frames for a new pair of glasses or contacts following surgery
Prior to getting surgery, confirm that the surgeon you are working with accepts Medicare plans. Not all surgeons and physicians do, so it is up to you to make sure the doctors you select accept Medicare. Also note, that any upgrades to the surgery, lenses, or frames you select will most likely not be covered by your Medicare plan.
Can Medigap Be Used for Additional Coverage?
Medicare.gov explains that the out-of-pocket expenses for services you receive through your MA Plan vary by plan and provider. Medicare pays a fixed amount each month to the company offering your MA Plan. The company must then adhere to Medicare regulations.
Companies offering MA Plans have some flexibility with their rules and offerings. Each company can determine if you are required to have a referral in order to see a specialist. They can also decide if you can only go to in-network providers to receive coverage. Additionally, theses rules can change each year, so it is important to stay up-to-date on your specific plan’s policies.
Unfortunately, Medicare Supplement Insurance, also known as Medigap, does not work with Medicare Advantage plans. Medigap cannot be used to cover copayments, deductibles, or premiums associated with an MA Plan. If you want to take advantage of a Medigap policy, you will need to switch from an MA Plan to Original Medicare.
Medicare Advantage Health Coverage
Medicare Advantage Plans, which are also referred to as Part C or MA Plans, provide a comprehensive alternative to Original Medicare. Private companies that have been approved by Medicare can offer Medicare Advantage Plans.
MA Plans are “bundled” plans, explains Medicare.gov, that include the following:
- Medicare Part A: hospital insurance
- Medicare Part B: medical insurance
- And usually, Medicare Part D: drug coverage
In addition to hospital and medical insurance, MA Plans offer coverage beyond what Original Medicare does. Some vision, hearing, dental, and fitness programs are covered. Plans can also choose to offer additional benefits, such as coverage for transportation to doctor visits, over-the-counter drugs, benefits to treat specific conditions, and health and wellness services.
If you are interested in purchasing a plan, you can shop for Medicare Plans online between October 15th and December 7th every year. Search for a coverage plan that is offered in the state where you live.
Each state has at least one private insurance company offering Medicare Advantage Plans, and most states have multiple MA Plan providers. Not every plan offers vision coverage, but vision is offered by multiple plans in each state. If you are eligible for a Medicare Advantage Plan, ensure that vision coverage is included in the plan you are considering before you purchase it.
To be eligible for an MA Plan, you must meet the following requirements:
- Be age 65 or older,
- Or be receiving Social Security Disability Insurance for at least the past 24 months for a medically diagnosed disability,
- Or suffer from end-stage renal disease.
If you qualify for an MA Plan, routine vision care — including annual exams, contact lenses, and eyeglasses — is an additional benefit that is frequently offered. Each policy that offers vision care has stated policy options listed in the policy documents.
If you have questions about the vision coverage included in a plan you are looking at, you can contact the company directly. In some instances, companies may be willing to expand coverage with a supplemental vision option if you ask.
Getting Cataract Surgery Covered
Cataract surgery is a costly procedure that can cost thousands of dollars per eye. It is medically necessary for many people, particularly older adults.
Fortunately, cataract surgery is covered by Medicare Advantage Plans. As long as you work with in-network providers, you can expect relatively low out-of-pocket expenses for the procedure.
How Do Medicare Advantage Plans Work? Medicare.gov.
Medicare and Cataracts: Take the Fear Out of Removing Cataracts. Medicare Consumer Guide.
Medigap & Medicare Advantage Plans. Medicare.gov.
Vision Coverage Under Medicare Advantage. (February 2020). Paying for Senior Care.