Does Aetna Cover Cataract Surgery?
- Aetna Medicare Advantage (Medicare Part C) plans cover cataract surgery when it’s medically necessary. While Original Medicare (Medicare Parts A and B) also covers cataract surgery, many Aetna Medicare plans cover additional vision services that Original Medicare doesn’t cover.
There are typically two questions that come to mind when told you need cataract surgery: How much does it cost and is it covered by insurance?
The average cost of cataract surgery is between $3,500 and $7,000 per eye. And yes, most health insurance plans cover cataract surgery when your doctor considers it to be medically necessary. All Medicare Advantage plans – including Aetna Medicare Advantage plans – cover cataract surgery when it’s medically necessary, though there may be some other conditions that must be met.
When Does Aetna Medicare Pay for Cataract Surgery?
Cataract surgery is often considered a medically necessary procedure, and your doctor will refer you for surgery upon a diagnosis of cataracts and vision impairment.
Some Aetna Medicare Advantage plans may require prior authorization before a coverage determination may be made. Some of the factors that may be used in making a determination include:
- Diminished ability to carry out activities of daily living
- A level of visual acuity of 20/50 or worse
- Significant improvement can be expected as an outcome of the surgery
Cataracts can affect your perception of colors and light, cause double vision, blurred or cloudy vision, seeing “halos” around lights, and increasing difficulty seeing at night.
Aetna Medicare Advantage plans – like all Medicare Advantage (Medicare Part C) plans – are required by law to cover at least as much as Original Medicare (Part A and Part B) covers. Because Original Medicare covers cataract surgery if it’s performed using traditional techniques or using lasers, Medicare Advantage plans will offer at least that same level of coverage, if not more.
Most Medicare Advantage plans offer additional benefits that Original Medicare doesn’t cover, such as prescription drug coverage, dental, hearing, transportation and more.
Aetna Medicare Advantage plans that include vision benefits typically cover routine vision care, eyeglasses or contact lenses, eye exams and more.
How Much Does Cataract Surgery Cost?
Your cost for cataract surgery with Aetna insurance will depend on your specific plan benefits.
For example, Original Medicare cost for cataract surgery. Beneficiaries are responsible for meeting the Part B annual deductible ($203 in 2021) and a 20% coinsurance payment for the remaining balance of the Medicare-approved amount.
The costs for removal of the cataract, the implant of a basic lens and a set of prescription eyeglasses or contact lenses after the procedure are all subject to your Part B deductible and copay amounts in this example.
Let’s consider a cataract surgery costing – as an example – $4,000 per eye for a total of $8,000. A Medicare Part B beneficiary in 2021 who has not paid anything toward their yearly deductible would be responsible for paying the first $203 of the cost. Then, the beneficiary would be responsible for 20% of the remaining $7,797, which is $1,559.40. The deductible ($203) plus the copay ($1,559.40) equals a total cost to the beneficiary at $1,762.40 for cataract surgery on both eyes.
While Original Medicare coverage can be used as a baseline, it’s important to keep in mind that the cost of cataract surgery can fluctuate depending on where you live and different Aetna Medicare plans may feature different deductible and copay amounts.
If you are enrolled in an Aetna Medicare Advantage plan, contact your plan directly to inquire about your cataract surgery benefits.
Does Aetna Cover Laser Cataract Surgery?
You would need to check with your Aetna plan directly to confirm whether coverage of cataract surgery extends to laser techniques.
Original Medicare covers the use of lasers, which means Aetna Medicare Advantage plans cover laser cataract surgery as well. Laser surgery, however, could potentially come with higher out-of-pocket costs for a beneficiary than traditional surgical techniques. Be sure to check with your doctor and your insurance plan carrier.
Your Aetna insurance or Aetna Medicare plan may have its own restrictions and conditions regarding the use of lasers or premium lenses.
Does Aetna Medicare Pay for Eyeglasses?
Aetna Medicare Advantage plans are required to cover one set of eyeglasses or contact lenses following a cataract surgery. This coverage requirement is in line with federal law that mandates Medicare Advantage plans meet the benefit minimums set forth by Original Medicare.
In addition to covering a set of eyewear after cataract surgery, many Aetna Medicare Advantage plans also cover prescription eyeglasses and contact lenses on a regular or annual basis. This usually includes an annual reimbursement of a set dollar amount to apply toward a new set of eyeglasses or contact lenses.
You will likely need to receive your glasses from an eye doctor or eye care center that accepts Aetna insurance and participates in your plan.
What Other Vision Benefits Does an Aetna Plan Include?
In addition to cataract surgery, Aetna vision insurance and Aetna Medicare Advantage plans can often include coverage of annual eye exams, glaucoma screenings, eyeglasses and contact lenses and discounts on LASIK eye surgery.
Aetna individual and employer-based plans generally require vision coverage to be added on as a standalone benefit. In Aetna Medicare Advantage plans, vision benefits are usually included at no extra cost.
How Can I Enroll an Aetna Medicare Advantage Plan?
Contact a licensed insurance agent to learn about any Aetna Medicare Advantage plans available where you live, and be sure to ask about each plan’s cataract surgery coverage and other vision benefits.
An agent will also be able to review your Medicare Advantage eligibility and help you through the enrollment process.