Medicare covers most of the cost of cataract surgery, but you will pay a portion depending on whether you have Original Medicare or a Medicare Advantage plan

Under Original Medicare (Part A and Part B), Medicare pays 80 percent of the approved amount for cataract surgery after you meet your Part B deductible. You pay the remaining 20 percent, which is called coinsurance. The exact dollar amount you owe depends on what your surgeon's charge is and whether they accept Medicare's approved amount as payment in full.

If you have a Medicare Advantage plan (Part C), your out-of-pocket costs work differently. Each plan sets its own copay or coinsurance for surgery, and these vary widely — some plans charge a flat copay (for example, $250), while others charge a percentage of the cost. You should check your plan documents or call the plan directly to find out what you will owe before surgery.

Cataract surgery is considered medically necessary by Medicare when the cataract is affecting your vision enough to interfere with daily activities. Medicare does not cover the surgery if it is purely cosmetic or if your vision loss is mild.

Key Takeaways

  • Original Medicare pays 80 percent of approved cataract surgery costs after you pay your Part B deductible; you pay the remaining 20 percent coinsurance.
  • Medicare Advantage plans have their own copays or coinsurance amounts, which you must check in your plan documents or by calling your plan.
  • The surgery must be medically necessary — meaning the cataract is causing vision problems that affect your daily life — for Medicare to cover it.
  • If your surgeon does not accept Medicare, you may owe the full bill unless you have supplemental insurance that covers out-of-network providers.
  • Costs for premium lens implants or other upgrades beyond the standard lens are not covered by Medicare and are your responsibility.

How Original Medicare calculates your out-of-pocket cost

Your actual cost under Original Medicare depends on two things: whether you have met your Part B deductible for the year, and whether your surgeon accepts Medicare assignment.

The Part B deductible is a fixed amount you must pay out of your own pocket before Medicare begins to pay its share. Once you meet this deductible in a calendar year, Medicare pays 80 percent of all approved services for the rest of that year. If your cataract surgery happens early in the year and you have not yet met your deductible, you will pay the full deductible amount first, then 20 percent coinsurance on the remaining approved cost.

A surgeon who accepts Medicare assignment agrees to accept Medicare's approved amount as the full payment and cannot bill you for any amount above that. If your surgeon does not accept assignment, they can charge you more than Medicare's approved amount, and you will owe the difference on top of your 20 percent coinsurance. This is called balance billing. Before scheduling surgery, ask your surgeon's office whether they accept Medicare assignment.

What Medicare does not cover for cataract surgery

Medicare covers the surgery itself and the cost of a standard intraocular lens (IOL) — the artificial lens that replaces your clouded natural lens. However, Medicare does not cover upgrades or enhancements beyond the standard lens.

If you choose a premium lens implant — such as a multifocal lens that reduces your need for glasses, a toric lens for astigmatism correction, or a lens with blue-light filtering — you will pay the full difference between the standard lens cost and the premium lens cost out of your own pocket. This difference can range from several hundred to several thousand dollars, depending on the lens type and your surgeon.

Medicare also does not cover the cost of glasses or contact lenses you may need after surgery, even though most people need some vision correction afterward. Routine eye exams are covered by Medicare Part B, but only once every two years for people without diabetes and once yearly for people with diabetes.

Medicare Advantage plan costs for cataract surgery

Medicare Advantage plans must cover cataract surgery because it is a medically necessary service, but each plan decides how much you pay. Some plans charge a copay for outpatient surgery (a fixed dollar amount, such as $250 or $500), while others charge coinsurance (a percentage of the cost). A few plans may require you to meet an out-of-pocket maximum before coverage begins.

The best way to find your exact cost is to call your plan's customer service number — it is on your insurance card — and ask what you will owe for cataract surgery. Have your surgeon's name and location ready, because some plans charge different amounts depending on whether the surgeon is in-network or out-of-network. Out-of-network surgery typically costs you more.

Some Medicare Advantage plans also cover one pair of glasses after cataract surgery, which Original Medicare does not. Ask your plan whether this benefit applies to you.

Supplemental insurance and cataract surgery costs

If you have a Medigap policy (supplemental insurance), it may cover some or all of your 20 percent coinsurance for cataract surgery. Medigap plans are labeled A through N, and different plans cover different amounts. Plans C, D, F, and G typically cover the full 20 percent coinsurance for surgery, while other plans cover less or none of it. Check your Medigap policy documents to see what your plan covers.

Medigap does not explore if you have a Medicare Advantage plan — you can have one or the other, but not both. If you have Medicare Advantage and want supplemental coverage, you would need to switch to Original Medicare and buy a Medigap policy during an open enrollment period.

Timing and cost considerations before surgery

If you have not yet met your Part B deductible for the year, you may want to ask your surgeon whether the surgery can wait until the following calendar year — but only if your vision loss is not severe. Meeting your deductible early in the year means you will pay 20 percent coinsurance for the rest of the year on any other services you need, so the timing decision depends on what other medical care you expect.

If you are turning 65 and enrolling in Medicare for the first time, you can schedule cataract surgery once your coverage begins. There is no waiting period for cataract surgery under Medicare.

Ask your surgeon's office for an estimate of the approved cost before your surgery date. This helps you know roughly what your 20 percent coinsurance will be. The office can also tell you whether your surgeon accepts Medicare assignment and whether any balance billing applies.

What to ask your doctor and surgeon

Before cataract surgery, ask your surgeon these questions: Does your practice accept Medicare assignment? What is the estimated approved cost for my surgery? Will I need a premium lens implant, or will a standard lens work for my vision needs? What is the difference in cost between a standard lens and any premium options you recommend?

Ask your Medicare plan (either your Advantage plan or your Medigap insurer) what your exact out-of-pocket cost will be. If you have Original Medicare without Medigap, ask whether you have met your Part B deductible for the year.

Contact your eye doctor if you notice a cataract is developing and your vision is getting worse. Cataracts progress at different rates, and only your doctor can determine whether surgery is medically necessary right now or whether you can safely wait.

Frequently Asked Questions

Do I have to pay anything upfront before cataract surgery?

You may need to pay your Part B deductible upfront if you have not met it yet that year. Some surgeon's offices also ask for payment of your estimated coinsurance before the procedure. Call your surgeon's office and your Medicare plan to find out what they expect you to pay before your surgery date.

What happens if my surgeon charges more than Medicare approves?

If your surgeon accepts Medicare assignment, they cannot charge you more than Medicare's approved amount. If they do not accept assignment, they can balance bill you for the difference. Always confirm in writing that your surgeon accepts Medicare assignment before scheduling surgery.

Will Medicare pay for cataract surgery on both eyes at the same time?

Medicare will cover surgery on both eyes, but surgeons typically perform them on separate dates, usually one to two weeks apart. Each surgery is billed separately, so you will owe coinsurance for each procedure. Your Part B deductible applies only once per calendar year, so the second surgery will only require your 20 percent coinsurance.

Can I use my Medicare Advantage plan to get cataract surgery out of state?

Most Medicare Advantage plans cover emergency or urgent care out of state, but routine cataract surgery may not be covered if you go out of network. If you are traveling or moving, contact your plan before scheduling surgery to confirm coverage in the state where you plan to have the procedure.

What if I delay cataract surgery because of cost — will my vision get worse?

Cataracts progress slowly in most people, but delaying surgery when your vision is significantly affecting your daily life can make the cataract denser and harder to remove. This may increase surgical risk. Discuss timing with your eye doctor based on your vision needs, not just cost. Many people find that the improved vision after surgery is worth the out-of-pocket expense.