Start with your plan and the treating practice
Most wound care insurance coverage questions have two parts: what your plan pays for, and whether the practice treating you participates with that plan. Gateway cannot answer either one with certainty, because we are the coordinator, not the insurer or the treating practice. What we can do is point each question to the office that can answer it.
People in Greater St. Louis and the Metro East can ask us about Medicare, Medicare Advantage, Medicaid and commercial plans. Participation and benefits depend on the treating provider, your plan and the care needed. A plan name alone does not tell anyone whether a particular visit, dressing or service will be paid for.
Three things wound care coverage depends on
- The treating provider. Each practice decides which plans it participates with.
- Your plan. Two people with cards from the same insurance company can have different benefits, deductibles and rules.
- The care needed. A visit, a dressing, a piece of equipment and a ride may each fall under a different part of your benefits.
Coverage questions to ask your plan
Call the member services number on your insurance card. Write down the date, the name of the person you spoke with and any reference number.
- Does this practice participate with my plan?
- Do I need a referral from my primary care clinician for wound care visits?
- Does any part of the care need prior authorization, and who requests it?
- What will I owe for a visit at home, in a facility or in an office?
- How are wound dressings and medical equipment covered, and do they have to come from a particular supplier?
Our guide to insurance and cost questions for wound care has a longer list.
Questions to ask the treating practice
- Do you participate with my plan for this type of visit?
- Will your office check my benefits before the first visit?
- If authorization is required, does your office submit the request?
- Will I receive a bill from anyone besides your practice?
Gateway can help you reach the right person at the practice.
What to ask for each type of coverage
Original Medicare
Ask how Part B applies to clinician visits and supplies, what your deductible and coinsurance are, and whether you have a supplemental policy that helps with those costs. See Medicare and wound care questions to ask.
Medicare Advantage
These plans are run by private insurers. Ask about your plan’s provider network, referral rules and prior authorization rules, since they vary from plan to plan. There is more in Medicare Advantage and wound care questions.
Medicaid
Medicaid is run by each state, so Missouri and Illinois have different programs and rules. Many members are enrolled in a managed care plan with its own network. Ask which plan you are in and what it requires. Our guide to Medicaid and wound care questions covers both states.
Commercial and employer plans
Ask about your deductible, your copay or coinsurance, whether the plan uses a provider network, and whether visits at home are handled differently from office visits.
Prior authorization and referrals
Some plans require approval, called prior authorization, before certain services, supplies or equipment are provided. The practice or supplier usually requests it. Ask what an approval includes and how long it lasts. Our guide to understanding prior authorization for wound care explains the steps.
Referral rules are separate. You can contact Gateway without a referral, but your plan may still require one before it pays for a visit. See whether you need a referral for wound care.
Supplies, equipment and transportation
Dressings, equipment and rides often come from separate companies, each with its own plan participation, authorization requirements and costs. Ask each one directly. Our guide to questions about wound supply orders lists what to ask a supplier.
When Gateway helps arrange a supply order or a ride, that does not mean the item or service is paid for by Gateway or covered by your plan.
How to share insurance information
Please do not put insurance card images, member numbers or medical details in a website form. The request care form asks only for your name and phone number. When we call back, we will explain how to share plan information with the treating practice through an appropriate channel.
You can also call 314-325-0126 or reach us through the contact page.
Common questions
Does Medicare cover wound care at home?
We cannot tell you that a service is a covered benefit. That depends on your Medicare coverage, the treating practice and the care the clinician finds necessary. Ask the treating practice whether it participates with Medicare and what you may owe. If you have a Medicare Advantage plan instead of Original Medicare, ask the plan too, since its rules may differ.
What if I do not have insurance?
You can still call us. Say that you do not have coverage, and we can tell you which treating practice might be involved so you can ask about its self-pay policies before a visit is scheduled. If you may qualify for Medicaid, your state’s Medicaid office or a hospital social worker can explain how to apply.
My plan denied something. What can I do?
Ask the plan for the reason in writing, along with its appeal steps and deadlines. Then tell the treating practice or the supplier that submitted the request, since the ordering office may be able to send more information. The decision on an appeal belongs to the plan.
Does it matter that I live in Illinois and the practice is in Missouri?
It can. Medicaid is run state by state, and some Medicare Advantage and commercial plans have networks tied to a service area. If you live in the Metro East, tell us where you live and which plan you have when we talk by phone. Then ask your plan whether the treating practice participates for members at your address.