Ask people who’ve had cataract surgery whether it was worth it, and most will give you a resounding, “Yes!” Not only does the procedure do away with the filmy, cloudy, blurry impediment to your vision that’s been making life miserable for you lately, but there’s also the possibility of correcting vision problems you had back before your cataracts formed. All surgeries carry some risks, of course, but cataract surgery is among the most routine and successful operations in the world. Yet that still leaves some very important questions…Does Medicare cover cataract surgery? Does private insurance? In short, “Can I afford it?”
If you’re over age 65, then chances are you can afford “a” cataract surgery. Whether or not you can afford “the” type of surgery you most want is another question. Here’s what you need to know about cataract surgery cost.
How much a surgery ends up costing is going to depend on the surgical method and the type of intraocular lens (IOL) you have inserted. Briefly, the three types of surgery are:
Phacoemulsification. In which sound waves are used to liquify your old damaged lens, which is then vacuumed out through a small incision in the eye.
Extracapsular cataract surgery. In which the old lens is not broken apart but removed intact from the eye through a slightly larger incision in the eye.
Femtosecond laser-assisted cataract surgery (FLACS). In which the old lens is broken apart using a laser and then removed through a tiny incision in the eye which has been precision-cut using the laser.
The other major factor affecting cost is the type of synthetic lens (intraocular lens, or IOL) you have put in to replace the old damaged lens. The main types are:
All but fixed-focus monofocal lenses are considered “premium” IOLs and will add considerably to the cost of surgery.
How much you personally will shell out for cataract surgery depends on whether you’re paying for the whole thing out of pocket, whether you’ll be using private insurance, or whether you’ll be using Medicare.
Out-of-pocket. You’ll pay the most, of course, if you’re going it alone. That means that you’ll be paying for the surgical team, for any anesthesia, for appointment time, and for your new IOLs. Cataract surgery is not cheap. On average in the US, people who pay out of pocket for their surgeries end up settling to the tune of $3,500 to $7,000 per eye. Obviously that’s a very wide range. That’s because it covers a range from the most basic surgery…phacoemulsification with fixed-focus monofocal lenses…to the most expensive, which could involve FLACS with light-sensitive or astigmatism-correcting lenses or a difficult surgery on very mature cataracts that requires extra care. Other factors affecting price will include the desirability and reputation of the doctor, whether the procedure is performed in a hospital versus a clinic, and what kind of follow-up care is required.
The out-of-pocket cost for cataract surgery with insurance will vary depending on similar factors.
Most carriers will pay for all or a great portion of it, minus your deductible, if your doctor deems it medically necessary. Medical necessity is based not just on the presence of cataracts but on the degree of visual impairment they cause. The bad news is that most plans cover only a phacoemulsification type of surgery, so if you’re hoping for a FLACS (laser) you may be out of luck, and if your ophthalmologist thinks you need an extracapsular surgery to deal with difficult, mature cataracts, that will need to be worked out with the insurer.
Typically, for covered procedures, your insurance will cover the costs associated with the surgical team and the facility, as well as basic monofocal lenses. Premium lenses such as those that correct vision or can be adjusted post-surgically are add-on, out-of-pocket expenses in most cases, although it’s impossible to generalize about all insurance plans, so it’s always best to call up your provider and get a clear understanding of what is and is not covered.
Eighty percent of cataract surgeries in the U.S. are performed on Medicare participants. Like private insurance, Medicare covers cataract surgeries deemed medically necessary by doctors, to the tune of 80% of the cost, which also includes a prescription pair of glasses or contacts post-surgery. Medicare covers both traditional and laser (FLACS) surgeries. As with private insurance, however, only basic monofocal lenses are covered. That doesn’t mean that premium lenses are unavailable to you if you’re using Medicare, but it will increase your out-of-pocket expenses. Some people who want premium IOLs use Medigap insurance policies to cover the aspects of their surgery that don’t fall under traditional Medicare coverage. If you’re a Medicare participant and you’re trying to figure out the costs of the cataract surgery you have in mind, call your Medicare representative to discuss your options.
According to the US Centers for Medicare and Medicaid Services (CMS), it pays an average cost of cataract surgery on one eye of $1,711, with $528 going to the doctor and $1,183 going to the facility (having it done as an outpatient in a hospital rather than in an ambulatory surgical center adds $1,037 to the cost). After coinsurance under Medicare Part B, the surgery typically costs people about $341 out-of-pocket at a clinic and $549 at a hospital. Out-of-pocket costs for those using private insurance will, of course, vary based on the amount of their deductibles, copays, and exclusions.
If you’re on a tight budget and wondering whether to spend extra money on premium lenses versus upgrading to a laser procedure, your best bet is to splurge on the lenses. Although FLACS is often touted as being more precise, there isn’t a significant difference in outcomes between laser and traditional surgeries, and that includes the surgery experience itself, the recovery, and the result. Upgrading to laser will cost hundreds more. So will purchasing premium lenses. They can cost multiples of what your out-of-pocket outlay would be with monofocals, but at least it represents a real and long-lasting investment in your vision and thus your quality of life.
