Does Medicare cover wound care at home? Questions to ask first.

Why there is no one-line answer

Does Medicare cover wound care? We cannot answer that with a yes or a no. Medicare generally pays only for care it considers medically necessary, and only when that care is provided and billed under its rules. Whether a particular visit, dressing or piece of equipment meets those rules depends on the service, where it is given, who provides it and what the clinician documents.

Gateway is a coordinator, not Medicare and not the treating practice, so we cannot tell you that something is a covered benefit. We can help you ask the right office the right question.

Check which kind of Medicare you have

Check your cards first.

• Original Medicare. You use the red, white and blue Medicare card. It shows whether you have Part A, Part B or both.
• Medicare Advantage. You use a card from a private insurance company. The plan’s rules apply to you, so read Medicare Advantage and wound care questions instead.

The rest of this guide is about Original Medicare.

How the parts of Medicare relate to wound care

In general terms:

• Part A is hospital insurance. It deals with inpatient hospital stays, skilled nursing facility stays, hospice and some home health care.
• Part B is medical insurance. It deals with clinician services, outpatient care, some home health care, durable medical equipment and certain supplies.
• Part D is prescription drug coverage, sold through private plans.
• A Medicare Supplement (Medigap) policy or other secondary insurance may help with costs that Part A and Part B leave to you.

Clinician visits generally fall under Part B, wherever they take place. Ask the treating practice how it bills a visit at home or in a facility.

Clinician visits and home health are different benefits

Home health is nursing or therapy from a home health agency that participates in Medicare. It has its own eligibility rules, which include a clinician’s order and being homebound as Medicare defines it. Our guide to what homebound means for care at home explains that term.

A visit from a treating clinician is a separate service with separate rules. Some people have both at once: a home health nurse for dressing changes and a wound clinician who directs the plan. See home health and mobile wound care.

Questions to ask the treating practice

Before the first visit, ask the practice that will treat you:

1. Do you participate with Medicare, and do you accept assignment for these visits?
2. What should I expect to owe for a visit, given my Part B deductible and coinsurance?
3. Will you bill my supplement or secondary insurance, or do I need to do anything?
4. If you think Medicare may not pay for a service, will you tell me before it is done?
5. Who supplies the dressings or equipment you order, and will I get a separate bill?

Not sure which practice that is? Send a callback request or call 314-325-0126, and we will tell you.

Questions to ask Medicare

You can call Medicare directly or sign in to your Medicare account. Useful questions include:

• Have I met my Part B deductible for this year?
• Is my supplement or other insurance on file correctly, and which one pays first?
• Is this supplier enrolled in Medicare?
• How do I read my Medicare Summary Notice?

Every state also has a State Health Insurance Assistance Program, known as SHIP, that offers free Medicare counseling.

Costs to understand before care starts

With Part B, you generally pay a yearly deductible and then a share of the Medicare-approved amount, called coinsurance. A supplement policy may pay some or all of that share, depending on the policy.

Dressings and equipment follow their own rules and often come from a separate supplier. Our guide to questions about wound supply orders lists what to ask that supplier.

Original Medicare sends a Medicare Summary Notice that lists the services billed in your name. It is a statement, not a bill. Compare it with any bills you receive, and call the billing office if something does not match. For a wider checklist, see insurance and cost questions for wound care.

What Gateway can and cannot tell you

For people in Greater St. Louis and the Metro East, we can say which practice may treat you and help gather the records it needs. We cannot verify your benefits, quote what you will owe or promise that Medicare will pay. The insurance page explains who answers which question.

Original Medicare or Medicare Advantage: questions for each

The first thing to find out is which kind of Medicare the patient has, because the questions are different. The card in the patient's wallet usually tells you: a red, white and blue Medicare card means Original Medicare; a card from a private insurance company usually means a Medicare Advantage plan.

If the patient has Original Medicare, ask:

• Is there a supplement (Medigap) or other secondary insurance, and does it apply to clinician visits at home?
• Has the Part B deductible been met this year?
• Are there any visit limits or documentation the treating practice needs to provide?

If the patient has a Medicare Advantage plan, call the number on the card and ask:

• Is the treating practice in network for this plan?
• Does a home visit need a referral or prior authorization?
• What is the copay for a specialist visit, and is it different for a visit at home?
• Does the plan have its own rules for wound supplies, or a preferred supplier?

Our guide to Medicare Advantage and wound care goes deeper on plan rules.

The home health benefit is not the same as a clinician wound visit

Families often hear "Medicare covers wound care at home" and assume it means one thing. In practice there are two separate kinds of care at home, with different rules:

• Home health is care from a home health agency, usually nurses and therapists, under a physician's plan. Medicare's home health benefit has its own requirements, including being homebound. See Medicare and home health in Missouri.
• A clinician wound visit is a visit from a physician, podiatrist (DPM) or nurse practitioner who examines the wound, decides the plan and writes the orders. It is billed differently from home health, and it is what Gateway arranges.

Many patients have both at the same time. Gateway does not provide home health services and works alongside the patient's home health agency.

Questions about wound supplies and dressings

Supplies are often where unexpected bills come from, so it is worth asking early:

• Who will supply the dressings, and are they in network for the plan?
• How many dressings are allowed per month, and what happens if more are needed?
• Is there a cost per order, and who do I call if a shipment is late or wrong?
• If a home health agency is involved, are they bringing supplies, or is a separate supplier?

See questions about wound supply orders for a checklist.

What to have ready when you call 314-325-0126

When you call Gateway, it helps to have the patient's Medicare or Medicare Advantage card, any secondary insurance card, the name of the patient's primary doctor, a list of current medications, and a short description of the wound: where it is, how long it has been there and what has been tried. Gateway can explain what to ask the plan and help gather the information, but the plan decides what it pays. Our insurance page and Medicare and primary care at home have more.

This guide is educational only. It is not coverage advice and does not mean any visit or supply will be paid for.

Common questions

Related pages

• Wound care for seniors
• Wound care nurse at home
• Insurance and coverage
• Medicare Advantage and wound care
• Insurance and cost questions
• Prior authorization explained
• What homebound means
• Request care
• Medicaid and wound care questions