Is cataract surgery covered by medical insurance or vision insurance

A cataract is a painless, cloudy area in the lens of the eye. The lens is enclosed in a lining called the lens capsule. During cataract surgery in the Inland Empire, our surgeons separate the cataract from the lens capsule. In most cases, the lens is replaced with an intraocular lens implant (IOL). In most instances, with certain limitations, cataract surgery costs are covered under both private insurance plans and Medicare.

Private Insurance

Private insurance for cataract surgery is usually quite comprehensive but also quite variable. In most instances, private insurances cover a portion, if not all, of the Cataract Surgeon Fee, the Facility Fee, the cost of a Monofocal Lens Implant and the necessary follow up care after your Cataract Surgery. Private insurances vary in the deductible that they may require, the co-pay you might be responsible for and the percentage of each allowable expense that they might reimburse.

Medicare Insurance

Medicare for cataract surgery is also quite comprehensive. Medicare generally covers a portion of the Cataract Surgeon Fee, the Facility Fee, the cost of a Monofocal Lens Implant and the necessary follow up care after your cataract surgery. It is likely that you will be responsible for a co-pay or a deductible for the pre-surgery office examination, consultation and measurements for your cataract surgery. If you need a pre-surgery physical with your medical doctor, you may also be responsible for that physician’s co-pay as well. In addition, if you require anesthesia, while your insurance will cover the allowable anesthesia expense, you may be responsible for the anesthesia co-pay and/or deductible.

It is important to note that insurance may not cover the cost of advanced technology lens implants. The amount of coverage, deductibles and any co-pays are uniquely individual to each patient’s specific health insurance policy.

To find out if your insurance plan will cover the cost of cataract surgery, contact Pacific Eye Institute at (800)345-8979.

Other Posts

Practicing proper eye care is essential to maintaining your eyesight and the overall health of your eyes. It’s important to understand what the most common eye diseases are, so you can be aware of any changes to your eyes or vision because of injury, illness, or age.

For optimum eye health, you might want to make an annual eye exam part of your regular health care. You may also want to consider a good vision insurance plan, in order to cover costs associated with eye care. 

If you suffer from common eye problems, you may find yourself wondering “Is an ophthalmologist covered by medical insurance or vision insurance?” In short, most opthamologists take both medical and vision insurance, depending on the type of procedures you’re having done. Continue reading to learn more about opthamologists and whether your insurance will cover them.

Common eye problems

Early detection of most eye problems can be essential in treating them. This is one of the reasons why annual eye exams are so important to good eye care. Here are some of the most common eye problems:

Vision impairment: According to the CDC, the most common eye problems in the U.S. are due to refractive errors. Refractive errors in your eyes result in impaired vision, and include astigmatism (distorted vision), myopia (near-sightedness), hyperopia (far-sightedness), and presbyopia (inability to focus on close objects, usually in people aged 40 and older). Vision impairments such as these can often be corrected by eyeglasses or contact lenses and sometimes by surgery, such as LASIK.

Cataracts: Other common eye disorders include cataracts, which is essentially a clouding of the eye’s lens and is the leading cause of eyesight loss in the U.S. and worldwide. Stronger lighting and eyeglasses are initially effective against cataracts, but the majority of patients eventually require surgery, which can be quite safe and immensely successful depending on individual circumstances.

Glaucoma: Glaucoma, which causes damage to the eye’s optic nerve and can result in partial or total blindness, is another major eye disorder. In general, glaucoma is treated with medication (eye drops or pills) or surgery (traditional or laser). The goal is to prevent blindness in the patient.

Macular degeneration: People over 40 sometimes suffer from age-related macular degeneration, which results in blurred central vision. Central vision is essential for daily tasks, like reading and driving, so age-related macular degeneration can severely affect a person’s quality of life and independence.

Unfortunately, there is no treatment for age-related macular degeneration, but you can adopt some healthy habits (including exercise, avoiding smoking, and eating lots of leafy green vegetables) to slow the progression of the disease.

Diabetic retinopathy: Diabetic retinopathy is the leading cause of blindness in American adults, and it’s a common complication associated with diabetes. Diabetic retinopathy can be managed through careful control of a person’s blood sugar, blood pressure, and lipid abnormalities. For diabetics, an annual eye exam is very important and is typically covered by health insurance plans.

Conjunctivitis: An extremely common, if not always serious, eye problem is conjunctivitis. Often referred to as “pink eye,” conjunctivitis is an inflammation or infection of the conjunctiva, and it can affect one or both eyes. It can also be highly contagious. Conjunctivitis is relatively a minor eye disease, but it can develop into a more serious problem if not treated properly. The treatment depends on the cause (allergic, viral, bacterial, etc.), and it usually involves topical antibiotics or artificial tears.

Blindness: The Centers for Disease Control and Prevention (CDC) estimates that about 3.3 million Americans are legally blind, many of them because of age-related eye diseases. However, blindness can also be a result of diabetic retinopathy, which is becoming more common in the U.S.

Amblyopia: This is one of the most common vision problems in children. Also called “lazy eye,” amblyopia occurs when the eye and brain don’t work together properly. The brain favors one eye over the other, meaning that one eye is not being used normally. If not treated properly during childhood, amblyopia can lead to blindness. However, applying an eye patch over the healthy eye, causing the child to use the “lazy” eye, is often an effective treatment. Treatment might also include corrective eyeglasses or contact lenses.

Strabismus: This condition is another common eye disease that afflicts children. Strabismus causes eyes to cross in or turn out, and it can also lead to blindness if left untreated. Treatment should begin extremely early, sometimes even when the child is a week old, to minimize the progression of this eye disease. Treatment can also include corrective eyeglasses or contact lenses.

An ophthalmologist is someone who specializes in medical care of the eyes. They differ from an optometrist in that they are physicians who have undergone at least 12 years of medical training to earn their license as an ophthalmologist MD. An ophthalmologist is qualified to perform eye surgery, treat eye diseases and vision disorders. They’re also trained to perform vision tests and write prescriptions for eyeglasses and contacts. An ophthalmologist is also trained to recognize and identify health problems that affect the eyes, but have origins elsewhere in the body.

Other eye specialists

For any eye disease or eye problem, it’s always a good idea to consult with an eye specialist. Practitioners specializing in the treatment of eye and vision disorders include ophthalmologists, optometrists, and opticians.

As discussed prior, an ophthalmologist is a medical doctor licensed to practice medicine and surgery of the eye, and should always be consulted for any serious eye problem, including physical injury to the eye. 

An optometrist is not a medical doctor, but a specialist who generally provides eye care like vision testing and correction, as well as treatment and management of vision changes. Vision testing of this sort is usually not covered by your health insurance, but may be covered by a vision plan.

An optician is a technician trained to verify and fit eyeglasses and contact lenses, usually following the instructions of an ophthalmologist or optometrist. Optician services may be covered by a vision plan as well.

Why might you see an ophthalmologist?

You might see an ophthalmologist for issues that include common eye diseases such as macular degeneration or glaucoma. However, the most compelling reason to go is because you have a medical condition in one or both of your eyes. Some of the more common eye problems include:

Sudden changes in vision 

Some changes in vision are normal and are the result of genetics or age. Sudden changes, such as blurriness or even a change in the floaters in your eyes, can indicate that there’s something serious going on with your eyes that an optometrist can’t help with. 

Double vision

Double vision can be an indicator of nerve injury or a brain condition making itself known. An ophthalmologist can investigate further and determine the cause of the issue.

Eye infections

Sometimes an eye infection progresses to a point where it causes issues with your vision. The ophthalmologist can diagnose the condition and prescribe the appropriate treatment to prevent an infection from damaging your eyes. 

Do opthamologists take medical insurance or vision insurance?

Do ophthalmologists take medical insurance or vision insurance? The answer is yes to both. Which type they take for your care depends on the reason why you’re seeing the ophthalmologist in the first place. An ophthalmologist can prescribe vision correcting aids as well as take care of your eye’s healthcare needs for cataracts, diabetic complications, macular degeneration and more. If you’re still asking “are ophthalmologists covered by medical insurance?”, rest assured, they are covered by your health insurance. 

Medical insurance vs. vision insurance

The difference between medical insurance and vision insurance comes down to the classification of the type of treatment you’re receiving. When looking at what insurance covers opthamologist visits, you’ll find your health insurance is used for coverage. Vision insurance, whether it’s group vision insurance or an individual policy, covers visits to the optometrist, but may also cover some treatments provided by an ophthalmologist.  

For example, you go to an optometrist for a routine vision exam. The optometrist takes your group vision insurance for the visit and any other services you need that are covered by the policy. If the optometrist discovers a health condition in your eyes that requires medical intervention, they’ll refer you to an ophthalmologist who can provide medical care for the condition. 

Here’s how each type of insurance covers vision care:

Medical insurance

Medical issues with your vision are ones that require the help of an ophthalmologist for treatment and resolution. These issues are considered medical due to the fact you need a physician to treat the condition and prescribe medication, but not necessarily prescribe vision correcting aids such as glasses. 

Vision insurance 

So, what is vision insurance, especially if medical insurance covers certain types of vision care? Vision insurance provides coverage for eye exams, corrective lenses, eyeglass frames, contacts, and discounts on LASIK, special coatings for lenses and progressive lenses. 

Annual eye exams and vision insurance

An annual eye exam can help you maintain good, clear vision and overall eye health. Annual eye exams are not only for people with vision problems, these exams can also check the overall health of your eye, diagnose any issues, and treat any disorders. If you experience any problems with your eyes, such as pain or huge changes in vision quality, you’ll want to to see an eye doctor right away.

Under the Affordable Care Act (or ACA, also referred to as “Obamacare”), all qualified health plans must cover many eye diseases, including glaucoma, cataracts, amblyopia, strabismus, diabetic retinopathy, and age-related macular degeneration. These are all considered to be medical problems and are covered by your major medical insurance plan.

Additionally, the Obamacare qualified health plans are required to include pediatric vision coverage for all patients under 19 years of age, including an annual eye exam and eyeglasses, if necessary.

However, the overwhelming majority of qualified health plans under Obamacare don’t offer vision coverage for adults. This means that your major medical insurance plan quite possibly doesn’t cover vision problems due to refractive errors or mild but common eye diseases like conjunctivitis. So, if you need adult vision coverage, including coverage for an annual vision exam plus benefits such as eyeglass lenses and frames, partial coverage for LASIK procedures, and so on, you may want to consider purchasing a stand-alone vision insurance plan.

Find vision insurance with eHealth

You don’t have to worry about getting coverage for vision care provided by an ophthalmologist, as your health care insurance typically covers the cost of care for physical issues with your eyes. However, you’ll need vision insurance to cover exams and corrective lenses. At eHealth, we want to help you save money and get the most out of your vision insurance. Check out our selection of vision insurance providers to learn more about vision insurance policies and how much they cost. 

We can help you find out more about the various vision plans available to help safeguard your eyesight.

• Just call eHealth agents at 1-866-787-8773, TTY users 711; Monday through Friday, 8AM to 8PM ET, Saturday, 9AM to 6PM ET.
• Or, visit eHealth’s vision insurance center and get a quote.

This article is for informational purposes only. Nothing in it should be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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