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Cataracts and Insurance: Find Out if You’re Covered

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If you have developed cataracts, there may come a time when they require surgery. This procedure removes the diseased lens in your eye and replaces it with an artificial lens called an intraocular lens (IOL). Most people receive a monofocal IOL, so they will need reading glasses to see up close, such as when they read, but they will be able to see clearly in general, which improves their quality of life.

You may worry about the cost of cataract surgery, even though it is medically necessary. It is important to know that many health insurance programs, not vision insurance specifically, will cover the treatment of cataracts including surgery because it is medically necessary for a healthy population. Although different types of IOLs, newer approaches to surgery, and multiple pairs of glasses will not be covered by insurance, you have a good chance of getting this important, life-changing procedure covered almost entirely by a basic health insurance plan.

If you have questions about what is covered by insurance, what is considered an “extra,” and what the overall costs might be for you, keep reading. You’ll learn how you can approach your cataract surgery and aftercare with the help of your insurance company.

What Happens When Cataracts Require Surgery?

When you have cataracts, you may experience problems like blurry vision, double vision, spots in your vision, or changes to how you see color, especially tending toward yellowing. Cataracts occur because proteins in the lens of your eye begin to break down, leading to clouding or tinting of the lens, which can cause vision problems.

This condition progresses at different rates in different people. If you receive a diagnosis of cataracts, your optometrist or ophthalmologist will closely monitor the disease’s progress. If you lose enough vision, and corrective wear like glasses or contact lens do not make enough of a difference, your doctor may recommend that you undergo cataract surgery.

This type of surgery is an outpatient procedure, and healing time is a few weeks. As with any surgery, cataract surgery can be expensive. It is important to know how insurance covers this procedure and in what cases.

What Parts of Cataract Surgery Are Covered by Insurance?

You may be surprised to learn that vision insurance is not necessarily the route to take for cataract surgery. While the Affordable Care Act (ACA) has required that insurance companies cover some treatment options like mental health care, the act does not require vision insurance to cover some surgeries like cataract surgery. Most health insurance companies, which cover checkups, prescriptions, and other types of surgery, consider cataract surgery to be medically necessary, and they will cover at least part of the procedure.

However, the amount of your cataract surgery that is covered can vary. There are some diagnostic procedures and pre-surgery treatments that may be covered by your insurance or not, depending on what company covers you.

The basics of cataract treatment that are covered by most insurance plans include:

  • A comprehensive eye examination.
  • A scan of the eye to determine the appropriate corrective power for the intraocular lens (IOL).
  • The traditional cataract surgery itself.
  • Medication like eye drops associated with the procedure.
  • The monofocal lens implanted in the eye.
  • Post-surgery glasses.

Typically, an insurance company will not cover elective parts of cataract surgery, including different types of IOL and laser-assisted cataract surgery. This means that, if you want these, you will pay out of pocket for at least part of the procedure.

Other conditions not necessarily covered by your health insurance may include scanning for glaucoma or macular degeneration, using computerized ophthalmic diagnostic imaging of the posterior segment, or corneal topography testing. These may be covered by your vision insurance, but not your health insurance.

Treatments that are not likely to be covered by your insurance include:

  • Laser-assisted cataract surgery (LACS).
  • Mixed focus, accommodating monofocal, toric, and multifocal lenses.
  • Some diagnostic tests.

Your eye doctor or surgeon may begin some exams that are not covered, so after you are diagnosed with cataracts and it is determined that you need surgery, be clear with your medical team how you want to proceed. Although many of these tests are valuable, you have the right to decline them if you do not want to pay for them.

You can also call your insurance company or read your coverage details for the year to learn if cataract surgery is covered under your health insurance. If you speak to your insurance company, here are some questions to ask:

  • What aspects of cataract treatment, including surgery, are covered?
  • What will my costs be, as the patient?
  • If I have a health savings account, how can I apply that?

You can also investigate which eye surgeons near you cost less, and you may consider looking at outpatient surgery centers or eye surgery centers, which house several specialists in one location. You can also speak with your optometrist for recommendations, including those based on your finances.

What Does Cataract Surgery Cost?

The cost of cataract surgery not only depends on the equipment used and the IOL implanted, but on the skill of the surgeon, your overall health, and where you live in the country. On average, cataract surgery costs about $5,000 per eye; however, in some places, this price can move up to over $10,000. If you need cataract surgery in both eyes, you may face $20,000 or more in total cost for the procedure.

  • Your insurance company and your health care provider can change how much the procedure costs by narrowing down what hospitals, doctors’ offices, and specialists are available to you in-network.
  • The amount of your copay and coinsurance amounts can determine what is available to you and whether you can pursue an out-of-network surgeon.
  • Your deductible also affects how much you may have to pay out-of-pocket.
  • If you have pre-existing health problems that must be managed while you are in surgery, this can impact how many specialists are in the room, how long the procedure takes, and what additional tools or medications must be used, thus raising the price.

What Do Different Insurance Companies Cover Related to Cataract Surgery?

Because cataracts are most likely to develop in people who are 40 and older, Medicaid and Medicare will cover basic cataract treatment and surgery. According to Medicare.gov, cataract surgery is considered medically necessary. While other vision treatment is not covered by this government insurance program, cataract surgery is.

Medicare Part B will help cover the cost of reading glasses after cataract surgery, which will most likely be needed since monofocal lenses are covered by Medicare, but multifocal or toric lenses are not. The program also covers the cost of contact lenses after cataract surgery.

It is important to note that Medicare does not cover vision treatment except after a medically necessary procedure like cataract surgery. Part B provisions include the following:

  • You will pay 20 percent of the Medicare-approved cost of one pair of eyeglasses or some set of contact lenses after cataract surgery with a monofocal interocular lens.
  • The supplier of glasses and contact lenses must be enrolled in the Medicare program.
  • Any additional costs, such as upgraded lenses in glasses, must be covered by you.
  • The Part B deductible applies to these options.

Other major insurance companies follow similar coverage standards. For example, Cigna states that they do not cover treatment for most eye or vision problems, except in the event of:

  • Cataract removal.
  • Trauma to the eye that has damaged the lens.
  • Congenital cataracts (those formed in utero).
  • Congenital aphakia (absence of a lens in the eye).
  • Displacement of the lens.
  • Vision that is not correctible with glasses or contact lenses.

Cigna will cover the cost of a monofocal IOL to treat the above conditions because this procedure can dramatically improve vision. The insurance company does not state whether they cover the surgical procedure itself.

Aetna offers a slightly more generous plan, stating that for insurance members who have a Snellen visual acuity of 20/50 or worse due to cataracts, outpatient surgery is considered medically necessary. The insurance company does state that there are forms of inpatient cataract surgery, and these are not considered medically necessary except in certain conditions, like:

  • The individual has a higher level of necessary general medical treatment, so postoperative recovery must be supervised by a medical professional.
  • The optical procedure itself was complex, requiring an inpatient stay.
  • Multiple ocular procedures are required.
  • The individual is mentally or functionally incapacitated or ill, which increases the risk from recovery after surgery.

Like Medicare, Aetna covers basic preoperative tests, the surgery itself, monofocal lenses, and reading glasses or contact lenses after surgery. Also, like Medicare, Aetna does not cover several more intensive diagnostic tests, laser-assisted cataract surgery, refractive error treatment alongside cataract removal, or premium IOLs.

United Healthcare states in their policy, like Medicare, that cataract treatment including surgery is considered medically necessary, and surgery to repair this disease is covered. The plan covers:

  • One pair of eyeglasses after cataract removal surgery.
  • Hard or rigid contact lenses after cataract surgery.
  • The procedure itself, including basic diagnostic tests.

This insurance plan does not cover:

  • Sunglasses designed to reduce, prevent, or manage cataracts.
  • More than one pair of glasses or set of contact lenses after cataract surgery.
  • Prosthetic lenses beyond the IOL.

A smaller insurance company, Pacific Prime, considers cataract surgery to be medically necessary. The surgery is covered under the inpatient portion of their surgery plan, although cataract surgery is typically an outpatient procedure. They also cover glasses and contact lenses after the surgery, although it may be in addition to your basic health insurance plan.

Why Cataract Surgery Is Important

Although you may not be scheduled for cataract surgery as soon as this condition is diagnosed, your eye doctor will follow the disease’s progress and recommend surgery for you as soon as it is medically necessary. AARP reports that a recent study found that cataract surgery may increase your lifespan by improving your overall health, showing exactly how important this procedure can be.

The Journal of the American Medical Association, Ophthalmology (JAMA Ophthalmology) published a 20-year study involving 74,044 women, ages 65 and older, who developed cataracts which required surgery. In 41,735 women, there was a 60 percent lower risk of death after the cataracts were removed, although many of them had additional health problems compared to those who did not opt for cataract surgery.

The link, researchers believe, is with overall improved quality of life. Not only are post-surgery individuals able to see better, so they are less likely to suffer a serious accident, they experience reduced stress overall, which improves health in other ways. After cataract surgery, the women were able to exercise more and be more cautious when taking prescription medications. For them, driving and walking became safer. They were less likely to experience falls and other accidents.

Since many health insurance companies consider cataract surgery to be medically necessary, you have options for coverage if it becomes necessary for you to undergo this procedure. However, you may consider adding a vision insurance plan or saving up extra money, if you want something to help you see better than monofocal IOLs can. Still, the surgery itself, along with some devices and checkups, will be covered by many insurance programs around the United States.

References

  1. What Are Cataracts? American Academy of Ophthalmology (AAO).
  2. How Much Does Cataract Surgery Cost? (January 31, 2017). Amino.
  3. What Types of Insurance Policies Cover Cataract Surgery? ShareCare.
  4. Covered or Noncovered? The Cataract Menu. (November 4, 2011). Review of Ophthalmology.
  5. Cataract Surgery. American Optometric Association (AOA).
  6. Cataract Surgery. Medicare.gov.
  7. Eyeglasses/Contact Lenses. Medicare.gov.
  8. Cigna Medical Coverage Policy. (February 15, 2013). Cigna.
  9. Cataract Removal Surgery. (June 5, 2018). Aetna.
  10. Vision Care and Services. (July 1, 2018). UnitedHealthCare.
  11. Do You Cover Cataract Surgery? Pacific Prime.
  12. Cataract Surgery Guide. (July 2021). Ophthalmic Consultants.
  13. What You Need to Know About Vision Insurance. (October 2, 2020). AARP.

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