Aetna announced it they would no longer be requiring prior approval for cataract surgeries starting in July. Show Aetna, a managed care company, announced on June 30 that patients would no longer need pre-approval for most cataract surgeries starting on July 1. The announcement covers all patients except for those enrolled in Medicare Advantage in Florida and Georgia. The announcement comes 1 year after Aetna instituted a new policy that required pre-approval for all physician-prescribed cataract surgeries. The policy, which affected children born with cataracts to patients requiring emergency cataract surgery, had received criticism from the ophthalmology community. The American Academy of Ophthalmology (AAO) estimates that Aetna’s policy requiring pre-approval for cataract surgery affected between 10,000 and 20,000 Aetna beneficiaries who had their cataract surgery delayed in the July of 2021 alone. “Aetna’s decision to impose a prior authorization (PA) requirement for cataract surgery was very difficult to understand since the indications for surgery are well established and the benefits clear,” said Stephen D. McLeod, MD, CEO of the AAO,in a statement. “And the immediate impact on patients subject to unnecessary delay should have been obvious.” The AAO, along with the American Society of Cataract and Refractive Surgery, provided data on patient cases that supported a rollback of the policy. Advocacy for the rollback included meetings with CMS and working with bipartisan Congressional leaders. The meetings with Congressional leaders led to the advancement of the Improving Seniors’ Timely Access to Care Act of 2021, which has received support from 300 US House members and 34 senators. The Act would streamline and standardize the PA process for patients with Medicare Advantage coverage, which would provide oversight, transparency, and protection from unnecessary delays and denials. The legislation would require the Medicare Advantage program to establish an electronic PA program, annually publish specified PA information, ensure PA requests are reviewed by qualified personnel, and protect beneficiaries from disruptions in care due to prior requirements. “We thank the original sponsors of the bills…for their steadfast leadership in advancing legislation that will help to ensure our nation’s seniors continue to receive the high-quality, timely care they deserve,” said David Glasser, MD, the AAO's secretary for federal affairs, in the statement. The AAO said their leadership will remain vigilant in protecting patients and physicians from abusive health insurance practices. Reference Big win for patients: Aetna drops prior authorization for most cataract surgeries. American Academy of Ophthalmology. June 30, 2022. Accessed July 1, 2022. https://www.aao.org/newsroom/news-releases/detail/big-win-patients-aetna-drops-prior-authorization In general, Medicare covers traditional cataract surgeries if they are medically necessary and the treating doctor accepts Medicare for payment. About 50% of adults have cataracts or have undergone cataract surgery by the time they reach 80 years of age. Typically, Medicare Part B — which is outpatient insurance — pays 80% of the expenses related to cataract surgery. This includes one pair of glasses following the surgery. If cataract surgery requires a hospital stay, Medicare Part A — which is hospitalization insurance — will cover it. Medicare Advantage, or Medicare Part C, plans provide the coverage of parts A and B. This article explains the costs of cataract surgery and which expenses Medicare will and will not cover. According to the American Academy of Ophthalmology, aging is the most common cause of cataracts. Normal proteins in the lens start to break down as a person becomes older. Over time, this breakdown causes cloudiness in the lens, which can interfere with vision. As of 2015, researchers estimate that about 3.6 million people in the United States undergo cataract surgery every year. Since surgeons generally perform cataract surgery on an outpatient basis, it falls under Medicare Part B. This covers certain post-surgical costs. Usually, Medicare pays 80% of the total surgical cost, consisting of the procedure itself and the facility charges. Medicare does not normally cover prescription glasses. The exception is one pair of spectacles or contact lenses after cataract surgery. The plan covers the following services:
Because various factors can affect the cost, people should check their annual deductible for Medicare Part B. Medicare Part A covers inpatient hospital stays. People do not usually require an overnight stay after cataract surgery. However, if a hospital stay is necessary due to significant complications, Part A will cover the extra accommodation costs. Medicare Advantage, or Medicare Part C, plans are the alternative to traditional Medicare. Because of this, they need to provide at least the same coverage for everything, including cataract surgery. Medicare Part D is a prescription drug plan available to people who have Medicare parts A and B. If a person with a Part D plan needs a prescription drug to take at home following cataract surgery, their plan will likely cover part of the cost. Medicare supplement plans, also known as Medigap plans, are private insurance policies that help people pay the 20% of costs excluded from Medicare coverage. For instance, these plans may pay deductibles, copayments, and other out-of-pocket expenses. Any person with Medicare parts A and B can apply for a supplement plan. Costs vary. A person with a Medicare Advantage plan is not eligible to buy a Medigap plan. Although Medicare usually covers cataract surgery that a doctor deems medically necessary, the requirements for coverage vary between regions. Before undergoing the procedure, a person may wish to check the regulations of their local Medicare carrier. Medicare does not cover the remaining 20% of the cost of cataract surgery. Plans may also exclude certain other charges, including deductibles and medications such as eye drops. An individual’s share of the cost of cataract surgery depends on the type of operation they need to have. Medicare pays the same amount toward cataract surgery whether a surgeon conducts it with or without a laser. However, laser surgery has a higher cost and is used for those who have astigmatism and need a premium lens implant. The surgical center will ask the individual to pay the difference between the covered amount and the additional costs of laser surgery. During cataract surgery, a surgeon inserts a type of lens called an intraocular lens (IOL). However, Medicare may not cover all types of IOL. It does pay for monofocal lenses, however, which surgeons typically use. Although other lenses, including multifocal and toric lenses, are available, Medicare may not cover these. It also does not pay for procedures exclusive to the implantation of these more advanced lenses that a surgeon would not perform for a traditional monofocal lens. Lifestyle factors and daily activities determine the best type of lens for a person receiving cataract surgery. They will need to discuss this with their eye surgeon and remain aware of the extra costs associated with more advanced lenses. To determine potential out-of-pocket costs, a person should ask the following questions before their surgery:
It is also good practice to ask for the Medicare code for the procedure, as this will help a person more accurately determine coverage through this online tool. Some researchers have found prices in the range of almost $2,700 for one eye and slightly over $5,200 for two eyes. However, the cost of cataract surgery can vary among states and individuals. For example, it may cost more depending on the type of procedure a person undergoes and whether the surgery takes place at an outpatient surgical center or a hospital. Surgeon fees also vary, which may affect the total cost of the procedure. In addition, the type of lens implant changes the price. It is best to discuss the overall charges with the surgeon for the most accurate picture of the eventual cost. Cataracts are some of the most common eye conditions to affect older adults. Surgery to correct them is usually successful. Medicare pays for cataract surgery as long as the doctor agrees that it is medically necessary. The cost of cataract surgery may vary. Medicare usually covers 80% of the surgical costs. People may wish to use Medicare supplement plans, such as Medigap, to cover the remaining 20% of the cost. For information about funding cataract surgery, it is best to speak with one’s insurance provider directly. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance. Does Medicare require authorization for cataract surgery?As with Original Medicare, you will also be responsible for the annual Part B deductible before your benefits kick in. MA plans will likely require prior authorization for the procedure, but Original Medicare will not.
How does Medicare work with cataract surgery?Original Medicare covers 80% of the cost of cataract surgery, and patients are responsible for paying the remaining 20% (either out-of-pocket or with supplemental insurance) after meeting their yearly Part B deductible. Medicare Advantage plans, however, may require a copay.
How Much Does Medicare pay for cataract surgery in 2022?Under Medicare's 2022 payment structure, the national average for allowed charges for cataract surgery in outpatient hospital units is $2,079 for the facility fee and $548 for the doctor fee for surgery on one eye. Of the $2,627 total, Medicare pays $2,101 and the patient coinsurance is $524.
Does Medicare require pre authorization?Medicare Prescription Drug (Part D) Plans very often require prior authorization to obtain coverage for certain drugs. Again, to find out plan-specific rules, contact the plan. Traditional Medicare, historically, has rarely required prior authorization.
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Does medicare require prior authorization for cataract surgery
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