If Medicare Covers Cataract Surgery, Why Are There Bills?

The daughter of a client called me because she was concerned about how much her mother paid for cataract surgery.

“She has a Medicare supplement, met her deductible and there shouldn’t be any bills. What is going on?”

As a nursing student, I cared for several cataract patients. They were admitted to the hospital and, after surgery, had to lay flat on their backs for three days. They were fitted for glasses with Coke-bottle lenses that looked like the bottom of a soda bottle. Many things have changed since then.

A Few Basics About Cataracts

Let’s review some facts about cataracts.

A cataract is a clouding of the naturally clear lens in the eye. Proteins in the lens break down and cause blurry or double vision, sensitivity to light, and difficulty seeing. In fact, the Centers for Disease Control and Prevention reported that cataracts are the leading cause of vision loss in the United States and the leading cause of blindness in the world.

Diabetes, hypertension, obesity, smoking, and excessive alcohol consumption are all causes of cataracts, so they become more common as people age. According to the National Institutes of Health. half of all Americans will have cataracts by age 80. In nursing school, every cataract patient I cared for was over 80.

Today, cataracts are affecting the vision of younger people. Data from the American Academy of Ophthalmology notes that more than 20 million Americans (17%) ages 40 or older have cataracts. One of the big contributing factors is exposure to ultraviolet light from the sun. There is also a somewhat newer scientific theory that points to the prolonged use of smartphones, tablets, and other electronic devices as a possible cause for the development of vision problems, including cataracts, in young people.

Learn more about cataracts – including the risk factors, causes, and symptoms – at the National Eye Institute website.

Cataract Surgery And Costs

Surgery is the only way to treat cataracts and that surgery is one of the most common procedures in the U.S. BMJ Open Ophthalmology found that almost four million procedures are performed every year.

Unlike the surgeries in my nursing school days, today’s procedure is done on an outpatient basis. It involves small incisions, removal of the cloudy lens, and replacement with an artificial plastic lens. Medicare Part B does help to cover the costs. For those who have Original Medicare, the Part B deductible and the 20% coinsurance apply. Any Medigap policy covers the coinsurance and Plan F also covers the deductible. With Medicare Advantage, there will likely be a copayment for the procedure. It’s important to note that the plan can also require prior authorization.

Medicare covers “cataract surgery that implants conventional intraocular lenses (within the eyeball).” This is generally a monofocal lens (for example, one point of focus) that can be for up close, medium range, or distance vision. Most people usually choose distance vision and then use glasses or contact lenses for reading or close work. Part B helps to pay for one pair of eyeglasses with standard frames or one set of contact lenses. The glasses are very basic. Medicare does not pay for tinted or oversized lens, progressive bifocals, scratch resistant or antireflective coating.

For those who would like to avoid glasses or contacts, there are several replacement intraocular lens options. And, based on my personal experience (I have had cataract surgery on both eyes), the replacement lens piles on the costs. I chose a lens to correct astigmatism and that choice can add $1,000-$1,500 or more to the bill, which exceeds Medicare’s allowance. However, now I don’t have the hassle and cost of contact lenses.

There’s one other part of cataract surgery that Medicare doesn’t cover completely: the eye drops before and after surgery. Generally, there are three types:

1. Antibiotics to reduce risk of infection;
2. Steroids to reduce pain and minimize risk of swelling that can blur vision; and
3. Non-steroidal drugs to reduce inflammation.

These drugs fall under Medicare Part D but each plan is different in coverage and costs.

As with most things, Medicare does not provide 100% coverage for cataract surgery. My client and others can pay out-of-pocket costs that include:

• The Part B deductible and coinsurance or the Medicare Advantage cost-sharing;
• Upgraded glasses or more than one set of contact lenses;
• The charge for an upgraded replacement intraocular lens; and
• The cost-sharing for eye drops.

Taking all of that into consideration, cataract surgery may not be cheap. But I do believe you’ll find that the improved vision is well worth the cost.