Cataracts and Insurance: Find Out If You're Covered | NVISION Eye Centers (2023)

If you've developed a cataract, there may come a time when it needs surgery. In this procedure, the diseased lens in your eye is removed and replaced with an artificial lens, called an artificial lensIntraokularlinse (IOL). Most people get a monofocal IOL, so they need reading glasses to see up close, like reading, but they will be able to see clearly overall, which will improve their quality of life.

You may be concerned about the cost of cataract surgery even if it is medically necessary. It is important to note that many health insurance programs, not specifically eye plans, cover cataract treatment, including surgery, because it is medically necessary for a healthy population. While various types of IOLs, newer surgical approaches, and multiple pairs of glasses aren't covered by insurance, there's a good chance that this important and life-changing procedure is covered almost entirely by basic health insurance.

If you have questions about what is covered by the insurance, what counts as "extras" and what the total cost could be for you, read on. You will learn how to approach your cataract surgery and aftercare with the help of your insurance company.

What Happens When Cataracts Need Surgery?

If you have cataracts, you may experience problems such as blurred vision, double vision, blurred vision, or changes in the way you see colors, particularly with a tendency to yellow.CataractThey occur because proteins in the lens of the eye begin to break down, causing the lens to become cloudy or darkened, which can lead to vision problems.

this stateprogresses at different speedsat different people. If you are diagnosed with cataracts, your optometrist or ophthalmologist will closely monitor the progression of the disease. If you lose enough vision and corrective wearers like glasses or contact lenses aren't making enough of a difference, your doctor may recommend cataract surgery.

This type of surgery is an outpatient procedure and the healing time is a few weeks. Like any surgery, cataract surgery can be expensive. It is important to know how insurance covers this procedure and in which cases.

What parts of cataract surgery are covered by insurance?

You may be surprised to learn that eye insurance isn't necessarily the way to gocataract surgery. While the Affordable Care Act (ACA) requires insurers to cover some treatment options, such as Most insurance plans that cover tests, prescriptions, and other types of surgery consider cataract surgery medically necessary and cover at least part of the procedure.

However, the scope of cataract surgeries covered may vary. There are some diagnostic procedures and preoperative treatments that may or may not be covered by your insurance, depending on which company insures you.

The basics of cataract treatment covered by most insurance plans include:

• A complete eye exam.

• A scan of the eye to determine the appropriate power of correction for the intraocular lens (IOL).

• Traditional cataract surgery itself.

• Medications such as eye drops related to the procedure.

• The monofocal lens implanted in the eye.
• Postoperative Brille.

Typically, an insurance company will not cover elective parts of cataract surgery, including different types of IOLs andLaser-assisted cataract surgery. This means that if you wish, you can pay for at least part of the procedure out of your own pocket.

Other conditions not necessarily covered by your health insurance may include screeningGlaucomaormacular degenerationB. using computer-assisted ophthalmic diagnostic imaging of the posterior segment or corneal topography test. These may be covered by your vision insurance, but not your health insurance.

Treatments that are unlikely to be covered by your insurance include:

• Laser Assisted Cataract Surgery (LACS).
• Mixed focus, accommodating monofocal,toric, zmultifocal lenses.
• Some diagnostic tests.

Your eye doctor or surgeon may order some tests that are not covered. Once you've been diagnosed with cataracts and it's determined that you need surgery, discuss with your medical team how you want to proceed. While many of these tests are valuable, you have the right to refuse them if you don't want to pay for them.

You can also call your health insurance company or read your coverage details for the year to find out if cataract surgery is covered by your health insurance. When speaking to your insurance company, you should ask the following questions:

• What aspects of cataract treatment, including surgery, are covered?
• What are the costs for me as a patient?
• If I have a Health Savings Account, how do I apply for it?

You may also want to investigate which eye surgeons in your area cost the least, and you might consider looking for outpatient or eye surgery centers that house multiple specialists in one location. You can also speak to your eye doctor for recommendations, including ones based on your finances.

How Much Does Cataract Surgery Cost?

The cost of cataract surgery depends not only on the equipment used and the IOL implanted, but also on the surgeon's skills, your general health, and where you live in the country. On average, cataract surgery costs about $5,000 per eye; In some places, however, that price can climb to over $10,000. If you need cataract surgery in both eyes, the total cost of the procedure can be $20,000 or more.

• Your insurance company and healthcare provider may change the cost of the procedure and limit which hospitals, doctor's offices, and specialists are available to you in their network.
• Your co-payment and co-insurance amounts may determine what is available to you and whether you can see an off-network surgeon.
• Your deductible will also affect how much you may have to pay out of pocket.
• If you have pre-existing medical conditions that need to be addressed during surgery, this can affect how many specialists are in the room, how long the procedure takes, and what additional tools or medications need to be used, all of which increases the price.

What do different insurance companies cover in relation to cataract surgery?

Since cataracts are more likely to occur in people aged 40 years and older,MedicaideMedicarecovers basic cataract care and surgery. According to Medicare.gov, cataract surgery is considered medically necessary. While other eye treatments are not covered by this state insurance program, cataract surgery is.

Medicare Part B will help cover the cost of reading glasses after cataract surgery, which will likely be needed since Medicare covers monofocal lenses but not multifocal or toric lenses. The program also covers the cost of contact lenses after cataract surgery.

It's important to note that Medicare does not cover eye treatments, except after a medically necessary procedure, such as an eye surgery. B. a cataract operation. The provisions of Part B include the following:

• You pay 20 percent of the Medicare-approved cost for a pair of glasses or a set of contact lenses after cataract surgery with a monofocal interocular lens.
• The eyeglass and contact lens provider must be enrolled in the Medicare program.
• Any additional costs such as improved lenses must be borne by you.
• These options are subject to the Part B deductible.

Other major insurers follow similar coverage standards. For example, Cigna states that treatment for most eye or vision problems is not covered, with the exception of:

• cataract removal.
• Trauma to the eye that damaged the lens.
• Congenital cataract (formed in the womb).
• Congenital aphakia (absence of a lens in the eye).
• lens shift.
• Vision that cannot be corrected with glasses or contact lenses.

Cigna will cover the cost of a monofocal IOL to treat the above conditions as this procedure can dramatically improve vision. The insurer does not say whether they will cover the surgical procedure themselves.

Etna offers a slightly more generous plan, according to which outpatient surgery is considered medically necessary for insured persons with Snellen vision of 20/50 or worse due to cataracts. The insurance company states that there are forms of inpatient cataract surgery that are only considered medically necessary under certain conditions, such as:

• The person has a higher need for general medical care, so postoperative recovery should be monitored by a doctor.
• The optical procedure itself was complex and required hospitalization.
• Multiple eye surgeries are required.
• The person is mentally or functionally disabled or ill, which increases the risk of recovery after surgery.

Like Medicare, Aetna covers basic preoperative testing, the surgery itself, monofocal lenses, and postoperative reading glasses or contact lenses. Like Medicare, Aetna does not cover several more intensive diagnostic tests, laser-assisted cataract surgery, treatment of refractive errors along with cataract removal, or premium IOLs.

United Healthcare states in its policy, like Medicare, that cataract treatment, including surgery, is considered medically necessary and surgery to correct this condition is covered. The plan includes:

• Glasses after cataract removal surgery.
• Hard or rigid contact lenses after cataract surgery.
• The procedure itself, including basic diagnostic tests.

This insurance plan does not cover:

• Sunglasses for reducing, preventing or controlling cataracts.
• More than glasses or contact lenses after cataract surgery.
• Prosthetic lenses beyond the IOL.

A smaller insurer, Pacific PrimeShe considers cataract surgery to be medically necessary. Surgery is covered in the inpatient portion of your surgical plan, although cataract surgery is usually an outpatient procedure. They also cover glasses and contact lenses after surgery, although they may be on top of your basic health insurance.

Why cataract surgery is important

Although you may not be eligible for cataract surgery once you have been diagnosed with this condition, your eye doctor will monitor the progression of the condition and recommend surgery as soon as it is medically necessary.AARP reports that a recent studyfound that cataract surgery can increase your life expectancy by improving your overall health, showing just how important the procedure can be.

The Journal of the American Medical Association, Ophthalmology (JAMA Ophthalmology)published a 20-year study of 74,044 women ages 65 and older who developed cataracts that required surgery. 41,735 women had a 60% reduced risk of dying after cataract removal, although many of them had additional health problems compared to those who did not choose cataract surgery.

The link, the researchers believe, is an overall improved quality of life. Postoperative individuals not only see better, suffer fewer serious accidents, they also experience an overall reduction in stress, which improves health in other ways. After cataract surgery, women have been able to exercise more and be more careful about taking prescription medications. Driving and walking has become safer for them. They had a lower risk of suffering falls and other accidents.

Since many health insurance companies consider a cataract operation to be medically necessary, you have the option of paying the costs if necessary. However, you might consider adding a vision insurance plan or saving some extra money if you want something that will help you see better than monofocal IOLs can. However, the surgery itself, along with some braces and tests, is covered by many insurance programs in the United States.

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