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Cataracts and Insurance: Find Out if You’re Covered

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Many health insurance programs will cover cataract surgery because it is medically necessary. Some types of lenses and newer surgical approaches aren’t typically covered.

If you have questions about what is — and what is not — covered by insurance, keep reading. You’ll learn how to approach your cataract surgery and aftercare with the help of your insurance company.

Is Cataract Surgery Covered by Insurance?

Cataract surgery costs are typically covered by Medicare and private insurance. Cataracts can severely limit your vision and impair your quality of life. Cataract surgery is the only solution, and most insurance companies consider it a medical necessity. 

While most companies cover cataract surgery, limits exist. It’s critical to understand what is and is not covered. 

For example, some plans will cover basic intraocular lenses (IOLs) to replace the versions clouded by cataracts. But if you choose newer versions, you may be required to pay for them. 

If you’re using Medicare for cataract surgery, your vision must be severely impaired by your cataracts. Opting for surgery before you meet those limits could cost you more. 

Every plan has specific criteria for insurance coverage. Some allow for more complex surgeries done early, and others require significant impairment before they’ll approve basic procedures. This table can help you understand typical differences:

Covered Not Covered
MedicareBasic surgery with standard lenses is typically covered once deemed medically necessary.Early surgery, advanced implants, and advanced surgeries may cost you more. 
Medicaid Basic surgery with standard lenses is typically covered once deemed medically necessary.Early surgery, advanced implants, and advanced surgeries may cost you more.
Aetna Surgery is covered once deemed medically necessary.Aetna covers some advanced lenses for people with specific health issues, and some people can get advanced surgery techniques too. 
Blue Cross Blue ShieldBasic surgery with standard lenses is typically covered, but benefits can vary between groups and contracts. Benefits can vary between groups and contacts. Some don’t cover advanced lenses or surgical techniques. 
Cigna Basic surgery with standard lenses is typically covered, but benefits can vary between groups and contracts.Basic surgery with standard lenses is typically covered, but benefits can vary between groups and contracts.
Humana Basic surgery with standard lenses is typically covered once deemed medically necessary.Early surgery, advanced implants, and advanced surgeries may cost you more.
United Healthcare Basic surgery with standard lenses is typically covered once deemed medically necessary.Early surgery, advanced implants, and advanced surgeries may cost you more.

What Does Cataract Surgery Cost?

On average, cataract surgery costs between $3,500 and $7,000 per eye. But your fees can vary due to a variety of factors, including some not within your control. 

Your potential expenses can include the following:

  • Surgeon fees
  • Facility charges
  • Anesthesia fees 

Some people opt for premium intraocular lenses (IOLs) to correct problems like age-related nearsightedness or astigmatism. Multifocal lenses can offer pristine vision after surgery, but they cost more than standard versions. Some insurance companies ask patients to pay the price difference. 

Some surgeons use laser-assisted cataract surgery to complete their procedures. Some companies won’t pay for these techniques at all, and others ask patients to make up the price difference. 

Potential Out-of-Pocket Expenses 

Insurance companies often use detailed rules to keep surgical costs low. Sometimes, those rules can add costs to your cataract budget. 

Before you schedule your surgery, ensure that you understand your policy’s rules regarding the following items:

  • Deductibles: Some plans require people to pay a specific amount before expecting the insurance plan to pay for anything. 
  • Coinsurance: Some plans require people to make payments for services after they meet their deductible. 
  • Copayments: Some plans require cost-sharing payments when you use your plan benefits. 
  • Preauthorization: Some companies require doctors to fill out paperwork and get clearance from the company before scheduling surgery. 
  • Limits: Some companies come with a payment ceiling cap, after which they will cover nothing else.

Factors Affecting Insurance Coverage of Cataract Surgery

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

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.
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.

Questions to Ask Your Insurance Provider

Before you schedule your cataract surgery, contact your insurance company. Answers to these questions can help you understand how much your surgery might cost:

  • Do I need prior authorization from you before I schedule my surgery?
  • Is there a copay for surgery?
  • Must I meet a deductible before the surgery?
  • How much is my coinsurance payment after I meet my deductible?
  • Can I use any surgeon I want, or is there a network I must choose from?
  • Can I use any facility I want, or is there a network I must choose from?
  • Can I use any lens I want, or are only basic versions covered?
  • How much more will I pay for advanced lenses?
  • Can my surgeon use advanced techniques, like lasers?
  • How much more will I pay if my surgeon uses advanced techniques?

Insurance Coverage for Cataract Surgery Frequently Asked Questions

Do most insurance companies cover cataract surgery?

Yes. Most insurance companies cover cataract surgery.

How bad do cataracts have to be for insurance to cover?

It depends. Some plans require low visual acuity tests, while others ask their members to describe the impact cataracts have on their quality of life.

Does cataract surgery fall under medical or vision?

Cataract surgery is typically part of medical insurance plans, but vision-specific plans may have advanced benefits.

Are all cataract surgery lenses covered by insurance?

No. Some plans only cover basic techniques and lenses.

Is laser cataract surgery covered by Medicare or private insurance?

It depends. Some plans cover these surgical techniques, and others do not.

References

  1. Cataract Surgery: Risks, Recovery, Costs. (July 2022). American Academy of Ophthalmology.
  2. Average Cost of Cataract Surgery in 2022. (January 2023). Becker’s ASC Review.

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