Medicare covers various healthcare services including medically necessary surgeries. It does not cover elective surgeries.
LASIK eye surgery is a procedure that may improve a person’s vision if they are near or farsighted, or have astigmatism. Medicare considers this surgery an elective procedure and does not cover the cost under original Medicare. However, some Medicare Advantage plans may cover LASIK eye surgery.
This article discusses LASIK eye surgery, and possible coverage through Medicare, including Medicare Advantage plans. It also looks at costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Laser-assisted in situ keratomileusis (LASIK) is a surgical procedure intended to improve vision. The procedure changes the clear covering over the eye, called the cornea, using an ultraviolet laser. It can help people with near or farsightedness, or astigmatism.
Generally, an ophthalmologist performs laser surgery on an outpatient basis. An ophthalmologist is a specialist eye doctor who can examine, diagnose, and treat the eye, and also perform eye surgeries.
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Medicare is a federal health insurance program.
- Part A provides hospital coverage
- Part B offers medical insurance
- Part C, also known as Medicare Advantage, is an alternative to original Medicare (Part A and Part B)
- Part D covers prescription drugs
Private-sector health insurance companies offer Medicare Advantage. Plans must provide at least the same coverage as original Medicare (parts A and B), and may offer additional benefits such as dental and vision coverage.
Medicare covers the surgery only when a doctor declares it medically necessary. If a person could use corrective glasses or contact lenses instead of having LASIK surgery, it would mean their sight and health do not rely on the LASIK procedure and it would not be deemed medically necessary.
In addition, original Medicare does not cover routine eye care, although coverage may be available for medically necessary eye exams or surgery related to another medical condition. For example, Medicare may cover certain eye care services related to diabetes, glucose, or if a doctor states a person needs cataract surgery.
A Medicare Advantage plan must provide the same level of coverage as original Medicare parts A and B. Most Medicare Advantage plans also offer additional benefits, including routine vision care, such as annual eye examinations, corrective glasses, or contact lenses.
However, Advantage plans do not always cover LASIK surgery, and a person would need to contact their plan provider to determine the exact coverage details.
A person with original Medicare can choose to switch to or enroll in an Advantage plan if the plan is offered in their area. Costs may include a plan premium, deductibles, and copays.
Generally, plans that offer in-network providers in a certain service area offer the lowest costs. Plans also have out-of-pocket limits, which can help a person avoid unexpected healthcare costs. Some plans may offer the choice of out-of-network coverage, although such plans may be more expensive.
Advantage Plans include:
- Health Maintenance Organization (HMO) plans: These plans use a network of providers who contract with the insurance company to offer discounted rates. A person enrolled in such a plan must use the in-network providers for medical care, unless in an emergency. Some companies also offer a point-of-service (HMO POS) option to go out of the network for some services but at a higher cost.
- Preferred Provider Organization (PPO) plans: These plans use an in-network of healthcare providers, although a person can go to a provider outside the network. The plans offer flexibility and are generally more expensive than some other plans.
- Private Fee-for-Service (PFFS) plans: Most PFFS plans use in-network providers, although a person may generally choose any doctor, in-network or outside the network, providing the doctor accepts payments from Medicare.
- Special Needs plans (SNPs): These plans offer enrollment only to people who meet certain criteria, including people with a chronic or disabling condition such as diabetes, or end stage renal disease, or a person living in a care facility or who needs home-based nursing care. A person who is eligible for Medicaid and Medicare may also be eligible for an SNP.
- Health savings account (HSA): A person enrolled in a HSA plan can choose their healthcare provider and services. The plans combine a medical savings account with a high-deductible insurance plan.
A person can use this online tool to search for Advantage plans in their area.
LASIK surgery costs depend on several factors, including where the surgery is done, the surgeon’s experience, and the technology used for the procedure.
However, if a person needs cataract surgery, it may be done as out-patient surgery, and Medicare Part B would cover the cost. Medicare Advantage plans generally also provide coverage for cataract surgery.
Although Medicare does not generally cover eyeglasses and contact lenses, it does provide coverage for one set following cataract surgery. The beneficiary must pay 20% of the Medicare-approved amount.
If the individual requires a more advanced lens implant, they may have to cover some costs.
A person considering LASIK surgery may get help to meet costs. This assistance may include pricing and incentives from private companies, coverage from a person’s employment health plan, and Flexible savings accounts (FSAs).
- Special pricing and incentives: These incentives may include no-interest financing, limited-time special prices, or discounts for pairs or groups of people that clinics offer.
- Financing: Some finance companies specialize in elective surgical procedures, including LASIK. These companies offer fixed rates and long-term payment plans. Clinics providing LASIK surgery may give out information about financing plans.
- Employer discounts: An employer may arrange employee discounts for LASIK surgery. Some large employers may have subsidized health plans that will cover some or all of LASIK’s cost.
- Flexible spending arrangements (FSAs): These plans are arranged with a person’s employer, with deductions from paychecks, to help pay for out-of-pocket medical expenses. The FSA may cover the cost of LASIK surgery.
Original Medicare does not cover the cost of LASIK or other elective surgeries. However, it covers costs associated with cataract surgery or for treatment of an eye condition such as glaucoma.
Typically, Medicare Advantage plans offer additional benefits above that of original Medicare, such as vision and dental care, although they may not cover LASIK.
If a person chooses to get LASIK surgery and does not have coverage from a Medicare Advantage plan, they may find private financing options or discounts.