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Self pay vs Medicare

Posted , 6 users are following.

Dapperdan7
Dapperdan7

so this is directed only to folks in the usa who have had the surgery. for those of you who had medicare pay for the operation, did you feel your choices were more constrained than might have been if you self paid? i know this might seem like an unanswerable question since if you did the former, you would not know the experience of the latter but im curious to know any opinions/ insights anyway. im not sure if doctors are paid the same amount in both cases (though i do know medicare is not as timely as payment as self pay).

0 likes, 13 replies

13 Replies

  • Bookwoman
    Bookwoman Dapperdan7

    Edited

    I was younger than Medicare age when I had my surgeries, but my insurance did what I believe Medicare would do; in other words, it paid for monofocal lenses, but if I had wanted toric, multifocals, etc., then I would have paid the difference. It seems to me that the only constraints are your wallet and how much information you have going in.

    Since the vast majority of people having cataract surgery in the US have either Medicare or Medicaid, I don't think it's a consideration for doctors. Upselling to a different kind of lens might be.

  • phil09
    phil09 Dapperdan7

    Edited

    It can vary, depending on what kind of Medicare you have. Most doctors, including all of the cataract surgeons with whom I consulted, do accept Medicare Part B, so that would not be a constraint for me at all. However, if you have Part C (Medicare Advantage), your preferred doctor may be in-network, out-of-network, or not covered at all.

    I'm assuming that by Medicare, you mean the American federal medical program.

  • RonAKA
    RonAKA Dapperdan7

    Posted

    As I am in Canada I can't offer any US personal experience. However, our government healthcare system in Canada may not be much different than Medicare. In Canada healthcare is provincial so the situation can vary from province to province. This said from what I see how the system works here, these would be the points to think about:

    .

    1. What is your choice of lenses? Can you get the lens you want, or the other way around, is what is offered OK with you. If you want something else do you get a credit for the basic lens offered, or do they chase you away and make you pay the full cost of an alternate lens from a private clinic.
    2. Does the service cover the cost of eye measurement with an optical instrument like the IOLMaster or Lenstar which is the most accurate? Or, does it only cover the cost of measurement with an ultrasonic instrument which is less accurate. Can you pay the upgrade cost to use the optical instrument?
    3. Does the service cover the cost of a topographical measurement with a Pentacam? Can you pay the extra cost to have it done. It is best to have this extra measurement if you are having a toric lens implanted.
    4. And on the soft side what is the attitude of the surgeon? Are they willing to listen to what you want for vision like near, far, or mini-monovision? Or, do they take the position that you are not paying for this service, so it is my way or the highway?
    5. How long do your have to wait to get in for surgery? If you are losing your vision due to the cataract can you wait? Here, when you go public healthcare it can be months or even up to a year to get in.

      .

      If you can get the lens you want, and the surgeon is considerate of your preferences then there may be no downside to going with Medicare.

  • jo61855
    jo61855 Dapperdan7

    Edited

    Medicare Part B pays about 20% of the bill, and you are responsible for 80%. A medigap policy may offer additional coverage.

    The surgeon's office account manager gives you the cost breakdown and papers to sign, as does the surgery center. The surgeon and I discussed the possibility of monovision as I had wearing contacts years before or the Vivity lens. She thought that monovision might cause depth perception problems, and recommended the Vivity lenses. As it turned out, I have a hybrid of Vivity and monovision. It would have been cheaper to use monofocal lenses, but I now get an extended depth of vision with less differential in lens power.

    • Bookwoman
      Bookwoman jo61855

      Edited

      Medicare Part B pays about 20% of the bill, and you are responsible for 80%.

      It's the reverse. Medicare pays 80% and you're responsible for the remaining 20%. A medigap policy should cover the rest, not counting your deductible.

  • jo61855
    jo61855 Dapperdan7

    Edited

    Medicare pays 80% of the amount they approve for the particular cataract surgery, which is not the same as 80% of what you are charged by the surgeon and surgery center.

    In my case, Medicare paid 20% of my bill.

    • Bookwoman
      Bookwoman jo61855

      Edited

      And were you billed for the difference? What doctors charge and what they'll accept as payment are two different things.

      Now that I'm on Medicare (with a medigap policy), I've yet to receive a bill from any sort of doctor for any sort of visit or procedure, something that happened often when I had private insurance. The same goes for my husband, who had major medical issues last year, surgery, etc. We keep waiting, but all the doctors so far have simply accepted the Medicare + medigap amounts they received.

    • phil09
      phil09 Bookwoman

      Posted

      Yes, a doctor that accepts Medicare Part B payments is prohibited by law from "balance billing" any excess over Medicare's allowed fee for covered services. They can bill deductible, coinsurance, and services that are not covered - such as the extra cost for a premium lens - and those things can be covered by a Medigap plan if you have one.

  • jo61855
    jo61855 Dapperdan7

    Posted

    I have Original Medicare, BCBS Medigap PlanF, and UHC/AARP Part D (Rx) with costly income related penalties. So I don't have deductibles or co-pays for office visits or out-patient tests. I use a Primary Care doctor because I like her, but can see specialists without a referral. I just accepted what the out-of-pocket would be for the cataract surgery and paid it.

  • maura04015
    maura04015 Dapperdan7

    Posted

    What about Medicare Advantage? I had a strange discussion with a neighbor the other day. Since she was getting irritated with me (and me with her), I just gave up and figure let her believe what she wants to.

    .

    She's on an Advantage program and told me she's paying $2,000 an eye out of pocket for her cataract surgery because if she doesn't they'll just put in a plain lens with no prescription, that she has to pay the extra for a lens that will enable her to see. What I was trying to tell her was that she's probably paying that for either toric lenses or some kind of premium lens or other extra. She didn't want to hear it. She's sure without the extra $$ she'd be left blind without glasses.

    .

    Now admittedly another neighbor who had cataract surgery last year paid extra for toric lenses and doesn't know they're for astigmatism but thinks they're just better lenses that hold their position better.

    .

    I plan to shut up on the subject. Let them believe what they want to, but the cost thing did bother me enough to have me checking what my own Medicare + supplement will/won't do. It's hard to believe an Advantage program doesn't do as well by a patient as regular Medicare with supplement. Does anyone know?

    .

    Also it sure looks to me as if in 2024 Medicare is going to pay for laser surgery?

    • phil09
      phil09 maura04015

      Posted

      Medicare Advantage plans are required to provide benefits for cataract surgery and other services similar to Medicare Part B. Generally, Medicare Advantage offers equal or lower out-of-pocket cost, but only if you use an in-network doctor. If you use a doctor who's not in the insurer's network, you can be required to pay more, and sometimes even the entire cost (if your plan is an HMO).

      It does sound like your neighbor is confused.

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