Medicare Advantage wound care coverage: questions to ask your plan.

How Medicare Advantage differs from Original Medicare

Medicare Advantage wound care coverage is decided by your plan, not by Medicare directly. Medicare Advantage plans, also called Part C, are offered by private insurance companies that Medicare approves. In general, they must cover the medically necessary services that Original Medicare covers, but they can set their own rules for how you get those services and what you pay.

That is why two neighbors with Medicare Advantage cards can get different answers to the same question. Gateway cannot tell you what your plan will pay for. The plan can.

Find your plan details first

Before you call anyone, pull together:

• Your plan member card, with the plan name, member ID and member services phone number
• The plan type, if it is printed on the card (for example HMO or PPO)
• The name of your primary care clinician, if the plan had you choose one
• Your Evidence of Coverage, the yearly document that spells out the plan’s rules and costs

Networks decide which providers the plan pays

A network is the group of clinicians, facilities and suppliers that have a contract with your plan. In general, HMO-style plans pay only for care from network providers, except in emergencies and a few other situations. PPO-style plans usually pay something toward care outside the network, but you pay more.

A treating practice, a home health agency, a dressing supplier and a lab can each have a different network status with the same plan. Ask about each one by name.

Plans also have service areas. If you live in the Metro East and the treating practice is based in Missouri, or the other way around, ask whether that practice is part of the network for members at your address.

Referrals and prior authorization

Some plans require a referral from your primary care clinician before you see another clinician. Our guide on whether you need a referral for wound care explains how referrals work.

Many Medicare Advantage plans also require prior authorization, which is the plan’s approval in advance, for certain services, equipment or products. The list differs from plan to plan. See understanding prior authorization for wound care for the steps.

Questions to ask your plan

Call member services. Write down the date, the person’s name and a reference number for the call.

1. Is this treating practice part of my plan’s network for visits at my address?
2. Do I need a referral for wound care visits, and who has to send it?
3. Do visits at home, in assisted living or in an office have different rules or costs?
4. Which wound care services, supplies or equipment need prior authorization?
5. Which suppliers and home health agencies does the plan work with near me?
6. What is my copay or coinsurance for each visit, and how close am I to my yearly out-of-pocket limit?

Questions to ask the treating practice

• Do you participate with my specific plan, not just the insurance company?
• Will your office check my benefits before the first visit?
• If a referral or authorization is needed, does your office request it?
• What will I owe at each visit, and how will I be billed?

Gateway can tell you which treating practice may be involved in mobile wound care in St. Louis and the Metro East. Start with a callback request or call 314-325-0126.

What you may pay

Each plan sets its own copays and coinsurance, so visit costs differ from plan to plan. Medicare Advantage plans have a yearly limit on what you pay out of pocket for covered Part A and Part B services. Ask what your plan’s limit is and which costs count toward it.

After a claim is processed, the plan sends an Explanation of Benefits that shows what was billed, what the plan paid and what you may owe. Our guide to insurance and cost questions for wound care shows how to keep a simple record.

If the plan says no

If the plan denies a request, ask for its decision and the reason in writing. You have the right to appeal, and the notice should explain how and by when. If waiting could seriously harm your health, ask whether the plan will make a fast decision.

Tell the treating practice about any denial right away, since its office may be able to add information. The insurance page explains who to contact for each kind of question.

Common questions

Related pages

• Insurance and coverage
• Medicare and wound care questions
• Prior authorization explained
• Do I need a referral?
• Insurance and cost questions
• Request care
• Medicaid and wound care questions
• Home health vs mobile wound care