Does insurance cover cataract surgery? What You Need to Know

Does insurance cover cataract surgery?

Health (medical) insurance typically covers cataract surgery, unlike vision insurance which doesn’t include this procedure.

Vision insurance focuses on reducing expenses for routine eye care like exams and glasses or contacts.

Cataracts, a prevalent age-related eye issue, affect about half of Americans over 75.

They develop as proteins in the lens deteriorate, forming a cloudy cluster that blurs vision and reduces color perception.

Those with cataracts may encounter light sensitivity, halos around lights, and night vision challenges, potentially leading to vision loss over time.

Does insurance cover cataract surgery
Does insurance cover cataract surgery
source :centerforsigh

What are cataracts?

Cataracts occur when the lens of the eye, a small clear disc, develops cloudy areas.

In youth, our lenses are typically transparent, enabling clear vision.

With age, they become frosted, akin to bathroom glass, impairing vision gradually.

Cataracts predominantly impact adults due to the aging process.

Does Insurance Cover Cataract Surgery?

Cataract surgery is commonly included, partially, in health insurance like Medicare, Medicaid, and ACA-compliant private plans from health insurance marketplaces.

Approval for coverage often hinges on the surgery being deemed “medically necessary,” meeting certain vision acuity thresholds, and impacting daily tasks.

Coverage terms vary across plans and often involve deductibles and copays.

Medicare Part B, within Original Medicare, covers 80% of approved costs for medically required cataract surgery after meeting the deductible, leaving 20% as your responsibility. Supplement plans could aid in covering these costs.

Both traditional and laser cataract surgery are eligible for coverage. Medicare Advantage plans from private insurers may also cover this surgery, though costs and responsibilities differ.

Certain services related to cataract surgery might not be covered, such as pre-surgery treatments, and premium IOLs may necessitate out-of-pocket expenses.

Consulting your insurance provider beforehand helps grasp your plan’s benefits and potential payments.

Importantly, cataract surgery usually falls under health insurance plans, not vision insurance, which typically doesn’t cover any part of the procedure.

What Does Cataract Surgery Cost?

Typically, cataract surgery expenses range from $3,500 to $7,000 per eye, subject to variation due to multiple factors, including uncontrollable elements.

Potential costs encompass various elements:

  • Surgeon fees
  • Facility charges
  • Anesthesia fees

Certain individuals choose premium intraocular lenses (IOLs) to address issues like age-related nearsightedness or astigmatism.

Multifocal lenses promise superior post-surgery vision but come with higher expenses compared to standard options.

Some insurers require patients to cover the cost difference.

While some surgeons utilize laser-assisted cataract surgery in their procedures, certain companies may not cover these techniques entirely, leaving patients responsible for covering the additional costs.

Factors Affecting Insurance Coverage of Cataract Surgery

The progression of this condition varies among individuals. Upon receiving a cataract diagnosis, your optometrist or ophthalmologist will closely monitor its advancement.

If vision loss becomes significant, and glasses or contacts aren’t effective, cataract surgery might be recommended.

Most health insurance providers, covering checkups and various surgeries, view cataract surgery as medically necessary and offer partial coverage.

Pre-existing health issues managed during surgery can affect the number of specialists present, duration of the procedure, and additional tools or medications needed, potentially increasing costs.

Certain conditions like glaucoma or macular degeneration screenings, computerized ophthalmic diagnostic imaging, or corneal topography testing might not be covered by health insurance but could be included in vision insurance.

Conclusion

Each medical or surgical procedure is identified by a CPT code, such as 66984 for standard cataract surgery and 66982 for complex cases.

These codes outline the procedure, akin to a “sticker price,” yet actual payments seldom match this figure.

Healthcare providers establish rates for various CPT codes, often negotiating them with insurance companies when “in-network.” Surgery codes may encompass post-operative visits within their costs.

For instance, a surgeon may set a “sticker price” of $1500 for cataract surgery but agrees to accept $900 from an insurer like Blue Cross Blue Shield (BCBS). Consequently, for a BCBS patient, the surgeon fee amounts to $900.

However, the payment source—BCBS or the patient—relies on the specific BCBS plan, including deductibles, co-insurance, and co-payments. Typically, an average patient might owe approximately $150 of the $900 based on prevalent plans, with BCBS covering the remainder.

Beyond surgeon fees, surgery incurs additional charges, namely the facility fee (paid to the hospital or surgery center) and the anesthesia fee (paid to the anesthesiology practice).

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