Does Aetna Medicare Cover Cataract Surgery?

If you’re wondering, “does Aetna Medicare cover cataract surgery?” The answer is yes. Cataract surgery is a covered benefit when deemed medically necessary, which typically involves an assessment of visual disabilities.

Most patients with Aetna Medicare can expect to have 80% of the procedure’s costs covered, leaving 20% as their responsibility.

In this article, we’ll dive into the essentials of what Aetna’s coverage includes in 2025, costs you might incur, and the benefits of selecting an in-network provider for your surgery.

 

Key Takeaways

  • Aetna Medicare covers cataract surgery with specific eligibility criteria, patients are generally responsible for 20% of the cost, and most cataract surgeries are outpatient procedures not necessitating an inpatient stay.

 

  • Patients must consider out-of-pocket costs like deductibles and copays for cataract surgery, with additional benefits from choosing in-network providers to reduce costs and ensure coverage.

 

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Clarifying Aetna Medicare’s Stance on Cataract Surgery

 

Does Aetna Medicare Cover Cataract Surgery?, Clarifying Aetna Medicare's Stance on Cataract Surgery

 

To summarize up front, Aetna Medicare offers coverage for cataract surgery. However, to be eligible for coverage, patients need to meet specific criteria related to visual disabilities, including a Snellen Acuity of 20/40 or better.

This requirement ensures that the surgery is medically necessary and not merely for cosmetic purposes.

Medicare covers 80% of the cost of cataract surgery, leaving patients responsible for the remaining 20%. This means that Aetna Medicare Advantage beneficiaries can expect a similar coverage percentage, with the remaining 20% typically being the patient’s responsibility unless supplemental insurance is in place.

It’s also worth noting that Aetna does not generally consider inpatient cataract surgery to be medically necessary. This policy underscores the fact that most cataract surgeries are outpatient procedures, allowing patients to return home the same day.

Navigating Coverage Details for Cataract Surgery with Aetna

Given that Aetna Medicare Advantage covers cataract surgery, you may be curious about the coverage specifics. Understanding the details can help you avoid unexpected expenses and ensure that you’re making the most of your benefits.

A significant factor to consider is out-of-pocket costs. This typically includes deductibles and copays that you’ll need to pay even with Original Medicare coverage.

Additionally, it’s crucial to consider the in-network requirements of your plan. Choosing an in-network provider not only guarantees coverage but can also potentially lower your out-of-pocket costs due to medical necessity.

 

Understanding Out-of-Pocket Costs

While cataract surgery is indeed covered by Aetna Medicare, you’ll still be responsible for certain out-of-pocket costs. These expenses can range from $207 to $783 per eye, depending on your specific Aetna plan.

Keep in mind, however, that not all services associated with cataract surgery are covered.

For instance, Optiwave Refractive Analysis (ORA) for cataract surgery is considered not medically necessary and thus may not be covered. Similarly, cosmetic procedures and sight-restoring surgeries that are not deemed essential are typically not covered.

 

In-Network Advantages

For those planning to undergo cataract surgery, choosing a provider within Aetna’s network is a wise decision. In-network providers are guaranteed to cover cataract surgeries when deemed medically necessary and even potentially offer additional vision-related services.

The cost savings of opting for an in-network provider provide another strong incentive.

Aetna’s network of health care providers offers comprehensive coverage at cost-effective rates, while out-of-network providers may charge higher fees and their services may not be fully covered, leading to increased out-of-pocket expenses.

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The Importance of Cataract Surgery for Seniors

 

Does Aetna Medicare Cover Cataract Surgery?, The Importance of Cataract Surgery for Seniors

 

The benefits of cataract surgery go beyond simply improving vision. For seniors, it can be a life-changing procedure, enhancing not just their sight but also their overall quality of life.

Cataract surgery, sight restoring surgery, replaces the clouded crystalline lens with an artificial intraocular lens, leading to clearer vision and enabling activities previously avoided due to poor eyesight.

This improvement in vision is crucial for cataract patients, as it directly impacts seniors’ depth perception and balance, both of which are essential for preventing falls – a prevalent and serious risk among this demographic, especially those with age related macular degeneration. Intraocular lenses play a significant role in enhancing the quality of life for these individuals.

In addition to enhancing vision and reducing the risk of falls, cataract surgery can also contribute to the prevention of dementia, further improving seniors’ quality of life. By providing seniors with clearer vision, cataract surgery opens a wider range of activities, thereby promoting cognitive health.

Additional Benefits for Aetna Beneficiaries

 

Does Aetna Medicare Cover Cataract Surgery?, Additional Benefits for Aetna Beneficiaries

 

Aetna Medicare Advantage beneficiaries enjoy more than just coverage for cataract surgery. In fact, the plan provides comprehensive vision care, including:

  • Yearly eye exams

 

  • Frames

 

  • Prescription lenses

 

  • Contact lenses

 

All supported by an annual allowance.

The annual eyewear allowance can be used for the purchase of frames, prescription lenses, and contact lenses, and it even covers one annual routine vision exam. Having yearly eye exams is beneficial as they can detect health issues early and help preserve visual acuity.

However, understanding what is not included in the coverage is crucial. Specialized lenses, such as transition or progressives, are typically not included in the coverage of Aetna Medicare Advantage plans.

It’s always advisable to review the benefit plan descriptions for more comprehensive information.

Preparing for Cataract Surgery: Steps for Aetna Members

Does Aetna Medicare Cover Cataract Surgery?, Preparing for Cataract Surgery: Steps for Aetna Members

As an Aetna member gearing up for cataract surgery, there are specific actions you need to take. One of the most crucial steps is choosing an in-network eye care specialist. This ensures coverage and can potentially reduce your out-of-pocket costs.

Another essential step is obtaining prior authorization for the surgery. While Aetna does not generally require prior authorization for cataract surgeries, members enrolled in Medicare Advantage plans in Florida and Georgia need to obtain it.

Your physician can submit a request to Aetna on your behalf for this prior authorization.

 

Selecting the Right Eye Care Specialist

Selecting an in-network eye care specialist for your cataract surgery is a crucial part of your path to improved vision. Not only does it guarantee coverage, but it can also reduce your out-of-pocket expenses. You can verify the network status of your eye care specialist by using Aetna’s ‘Find a doctor’ tool or the Aetna Vision provider locator.

Choosing an out-of-network specialist, on the other hand, could lead to increased expenses and potential exclusion of coverage for certain medically necessary services. Furthermore, you might end up being billed any amount by the doctor. Therefore, it’s always advisable to stay within Aetna’s provider network for your cataract surgery.

 

The Role of Prior Authorization

Obtaining prior authorization is an integral part of securing coverage for cataract surgeries. Until recently, Aetna required prior authorization for cataract surgery in different regions. But the current policy has made it easier for most beneficiaries, as prior authorization is no longer required, except for those in Florida and Georgia.

The change in Aetna’s prior authorization policy was spearheaded by the American Society of Cataract and Refractive Surgery (ASCRS) and the American Academy of Ophthalmology (AAO).

The goal was to alleviate the administrative workload on healthcare providers and ensure prompt medical attention for patients. Indeed, the previous policy had led to substantial delays for tens of thousands of cataract surgery procedures, negatively affecting patient care.

Vision Preservation Beyond Cataract Surgery

Does Aetna Medicare Cover Cataract Surgery?, Vision Preservation Beyond Cataract Surgery

 

 

Apart from cataract surgery, many Medicare Advantage plans, such as Aetna Medicare Advantage, provide further vision coverage to aid in maintaining your eyesight.

This includes:

  • Routine eye exams

 

  • Eyeglasses

 

  • Contact lenses

 

  • Other services

 

Regular eye exams are particularly important as they can detect health issues early and help maintain your visual acuity. These exams are typically covered on a yearly basis, ensuring that you have regular check-ups for your eyes.

Although Aetna Medicare Advantage plans cover corrective lenses post certain cataract surgeries, they generally do not extend coverage to routine vision care or glasses.

So, even after cataract surgery, it’s essential to continue taking care of your eyes and making the most of the vision benefits offered by your plan.

Summary

Cataract surgery can be a life-changing procedure for older adults, restoring clear vision and improving quality of life. As an Aetna Medicare Advantage member, you can rest assured that this crucial surgery is covered under your plan.

However, understanding the details of your coverage is key to avoiding unexpected expenses. Remember to consider out-of-pocket costs, choose an in-network eye care specialist, and obtain prior authorization if necessary.

By doing so, you’ll be well-prepared for your cataract surgery and on your way to clearer vision and an enhanced quality of life.

 

Frequently Asked Questions

 

→  Is Aetna denying cataract surgery?

Aetna has withdrawn the requirement for pre-approval for cataract surgeries, except for those enrolled in Medicare Advantage in Florida and Georgia.

This change came after sustained advocacy from the ophthalmology community.

 

  Does Aetna Medicare Advantage plans cover cataract surgery?

Yes, Aetna Medicare Advantage plans cover cataract surgery, but patients need to receive prior authorization.

 

→  Is cataract surgery covered 100% by Medicare?

Yes, cataract surgery is covered by Medicare, with Medicare Part B covering around 80% of the overall surgery costs after meeting the deductible. Patients will still have some out-of-pocket costs to consider.

 

  What are the out-of-pocket costs for cataract surgery under Aetna Medicare Advantage?

The out-of-pocket costs for cataract surgery under Aetna Medicare Advantage plans can range from $207 to $783 per eye, depending on the specific plan.

 

 Do I need to choose an in-network eye care specialist for my cataract surgery?

Choosing an in-network eye care specialist for cataract surgery ensures coverage and may reduce out-of-pocket costs.

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Speak with a licensed insurance agent

 1-833-641-4938
TTY 711

Mon-Fri : 8am-9pm EST

Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.