There are many variables in the cost of cataract surgery: type of intraocular lens (IOL), type of preoperative testing (basic or basic plus refractive), geographic location (urban vs rural), and length of postoperative care.
According to AllAboutVision.com’s 2012 report, the average, basic cataract surgery in the US would cost roughly $3,429 per eye if you paid everything yourself. If you wanted an advanced technology lens which corrects astigmatism or presbyopia, expect to pay an additional $449 or $895 per eye.
But Isn’t Cataract Surgery Covered by Insurance?
Yes, for most people! Most people undergoing cataract surgery qualify for Medicare or commercial health insurance to “cover” the procedure. “So the whole procedure is covered?” Yes and No. The whole part of the Basic Cataract Surgery is covered, while any Refractive Portion (Advanced or Premium) such as screening tests, Refractions, Astigmatism Correction, Presbyopic Correction, iLASIK or Excimer Laser surgery, Touchups, or extended postoperative care for a year (anything past the typical 90 days) is an out of pocket expense.
Take a single focus, advanced IOL for example. Medicare covers the whole cost of the part of the procedure which is medically necessary (Basic Cataract Surgery). This is because your natural prescription lens (cataract) is removed during the cataract surgery and an advanced, single focus IOL is implanted. This is medically necessary because your eye needs an artificial, prescription lens after the cataractous lens is removed in order to restore sight. Determining the basic prescription power of the IOL is a covered procedure as well. Advanced refractive testing (any type of testing to determine the refractive state of the eye), topography screenings, pupil screening, OCT screenings and other screening tests part of a refractive procedure are not covered by insurance, but may be recommended to achieve refractive results. The costs of any of these tests before cataract surgery should be very explicit and given to the patient. These refractive tests are not mandatory, but may be recommended to screen for issues which may impact great results with basic cataract surgery outcomes.
What about astigmatism correction? Same rules apply here. Remember that most commercial insurances and secondary insurance companies follow Medicare’s rules. Medicare usually determines that astigmatism correction is not a covered procedure since this can be corrected with glasses. Most studies indicate that correcting astigmatism in the eye through advanced cataract surgery is better than correcting astigmatism in the glasses, but Medicare still sees this as a non-covered procedure. Medicare will cover all of the medically necessary part of the cataract surgery including the cost of an advanced, non-Toric IOL. If a Toric, Astigmatism Correcting IOL is used or if a Limbal Relaxing Incision is used, Medicare and secondary insurances will not cover this part of the procedure, but the Basic portion is still covered.
I get the picture. Probably a Multifocal or Accommodating IOL (Presbyopic IOL) is not covered, right? Yes and no. Remember, Medicare (secondary or commercial insurance companies, too) still covers a majority of the surgery; most of the surgical cost is the basic, medically necessary portion-this is covered. The portion that relates to advanced refractive preoperative testing, presbyopia correction, the presbyopic IOL, and any extended postoperative care (days 91-365) is not a covered portion.
This doesn’t make sense. What’s the deal? Insurance companies state:
I’m still a bit confused because all of my friends and family who had cataract surgery could see great and didn’t have to pay any extra. Everyone is different and some people achieve different results. Be certain to ask your eye surgeon’s billing coordinator about a detailed description and costs. Remember, there are 2 major costs: The surgeon’s fee and the facility’s fee, each having portions which are part of the Basic Cataract Surgery and part of the Advanced Cataract Surgery. You get to choose if you want to have any of the Advanced Cataract Surgery portions. Each of the Basic Cataract Surgery portions will have associated copays and deductibles, while each of the Advanced Cataract Surgery portions are out-of-pocket charges you are responsible for paying to the doctor and facility.
Medicare and Health Insurance Coverage for Basic Cataract Surgery
If you choose to have Basic Cataract Surgery (no advanced preoperative refractive testing or astigmatism/presbyopia correction or extended postoperative care), then Medicare coverage is very easy to understand with respect to paying the surgeon and facility where the surgery is performed. Remember, most private or commercial health insurances tend to follow medicare’s rules on what is a covered procedure.
Questions to Ask Your Insurance Provider:
Credit: much of this article was paraphrased from AllAboutVision.com. For the whole article, read here: http://www.allaboutvision.com/conditions/cataract-surgery-cost.htm