Transcript (Cataracts and Medicare)

Introduction

Cataracts can make the world look cloudy or dim. Night driving may feel harder.

Over 50% of Americans aged 80 and up have cataracts or have had cataract surgery.

Risk factors include diabetes, smoking, steroid use, eye injury and too much ultraviolet light.

Medicare can help with prevention, diagnosis, treatment, recovery, and medications. Before we get into cataract surgery coverage, it helps to look at what Medicare covers overall. Part A covers medically necessary inpatient hospital stays and skilled nursing facility care. It also covers hospice and some home health services. Part B includes doctor visits, preventive services, durable medical equipment, and outpatient care. Part D generally covers prescription drugs you get from a pharmacy. Medicare A, B, C and D can include co-insurance, co-pays, and deductibles. In this video, we’ll walk through cataract surgery prevention, diagnosis, treatment, recovery, and medications.

Prevention

Medicare Part B covers most preventive services, including a Yearly Wellness visit. Those visits may support a cataract prevention plan. Medicare may cover certain eye exams or treatments when they are connected to a medical condition, such as diabetes, glaucoma risk, or macular degeneration.

Diagnosis

Cataracts are diagnosed through a medical eye exam. The doctor may check vision, glare, eye pressure, lens and retina. Medicare Part B covers medically necessary cataract related diagnostic tests, doctor visits, and outpatient care, subject to a deductible and 20% coinsurance. A Medicare Local Coverage Determination (LCD) explains that cataract surgery may be considered medically necessary when cataracts cause visual impairment that is not correctable with a tolerable change in glasses or contact lenses, and that impairment affects activities of daily living such as driving, reading, watching television, or other vocational or recreational needs.

Treatment

Cataract surgery removes the cloudy natural lens and places an artificial lens inside the eye.

That lens is called an intraocular lens [IOL]. Medicare Part B covers medically necessary outpatient cataract surgery, typically with a conventional intraocular lens.

The CMS National Coverage Determination (NCD) for intraocular lenses says IOL implantation services, as well as the lens itself, may be covered if reasonable and necessary for the individual. Medicare may cover standard cataract surgery costs, but patients may pay extra for premium lenses.

Recovery

Recovery is usually handled through follow-up eye visits. Most people use prescription eye drops for a short time after surgery. The doctor may also recommend an eye shield, activity limits, and follow-up visits. Medicare Part B covers one pair of eyeglasses with standard frames or one set of contact lenses [come from a supplier that participates in Medicare] after each cataract surgery that implants an IOL.

Medications

Medicare Part D usually covers prescriptions obtained at pharmacy. Prescription eye drops are common after cataract surgery, including antibiotics, anti-inflammatory drops, or steroid drops. They may reduce infection risk, swelling, or irritation.

Prescription drug coverage varies by plan rules, tiers, formulary, and pharmacy network. A formulary is a drug list covered by your Part D plan. A drug may require prior authorization, step therapy and quantity limits. Part B often covers drugs given in medical settings. In most cases, this involves drugs given via injection or infusion, and vaccines for prevention.

Medicare Advantage

If someone has a Medicare Advantage plan, cataract surgery is generally covered when medically necessary. With Medicare Advantage, additional rules come into play. All plans must include Medicare services; however, the guidelines can change. Network use, referrals, and prior authorization may affect access. Medicare Advantage plan rules can also affect costs and timing.

Final Thoughts

Cataract surgery can make daily life easier. Before surgery, ask three important questions.

Is this medically necessary and documented? What will Medicare or my plan cover?

And what will I owe out of pocket? Always confirm coverage with Medicare, your doctors, and your plan. And it can make the whole process feel easier.