Medicare generally covers wound care and supplies, although out-of-pocket costs may vary between original Medicare, Medicare Advantage, and Medigap.
Wounds may range from scratches and cuts to punctures in the skin. They will generally need to be cleaned, while more serious wounds may need a visit to the doctor or the hospital.
This article examines Medicare coverage of wound care and supplies, the out-of-pocket costs, and coverage rules. Then, it discusses the types of wounds that need dressings, along with what to expect in a wound exam and what people can do to help their wounds heal.
The various parts of Medicare (Part A and Part B), Medicare Advantage (Part C), and Medicare supplement plans (Medigap) provide different wound care coverage.
Original Medicare Part A is hospitalization insurance and provides coverage if a person’s wounds need a surgical procedure. Medicare Part B is medical insurance and covers the services of a healthcare professional to dress a wound, and the supplies used for that care.
Original Medicare coverage includes:
- Part A covers care, including wound care, that someone receives in a hospital or skilled nursing facility for a limited number of days.
- Part B covers wound care and supplies an individual receives in a doctor’s office or other outpatient settings.
Medicare Advantage (Part C) is the alternative to original Medicare and provides parts A and B coverage for wound care and supplies. Many Advantage plans come with additional benefits, such as prescription drug coverage and dental care.
Medigap is Medicare supplement insurance that a person with original Medicare may buy. It helps pay between 50 and 100% of costs associated with parts A and B, such as deductibles, copays, and coinsurance.
A person can use this online tool to find a Medigap plan.
Medicare covers a stay in a skilled nursing facility for only the first 100 days. If a person’s wounds necessitate a longer stay, they must pay the entire cost.
Another uncovered cost is custodial care. Someone’s wounds may make it difficult for them to perform activities of daily living, such as bathing and dressing. If they hire an attendant to provide this care, they must pay all costs.
The out-of-pocket costs vary between original Medicare parts A and B, Medicare Advantage, and Medigap.
If a person gets wound care while in a hospital, the costs include:
- $1,408 deductible for each benefit period
- $0 coinsurance for first 60 days of each benefit period
- $352 per day coinsurance of days 61–90 of each benefit period
- $704 coinsurance after day 90 for each benefit period (up to 60 days over a person’s lifetime), for each ‘lifetime reserve day’
- all costs after the ‘lifetime reserve days’
When someone gets wound care in a skilled nursing facility, the coinsurance is:
- $0 for days 1–20 of each benefit period
- $176 per day coinsurance of days 21-100 of each benefit period
- all costs after day 101
A benefit period starts the day a person enters a hospital or facility and ends the day after they have been out of the hospital or facility for 60 consecutive days.
If wound care takes place in an outpatient setting or in a person’s home, the costs fall under Part B. Medicare does not charge for the supplies.
However, expenses for care include:
If someone receives wound care in an outpatient hospital setting, when the service could be done in a doctor’s office, they may have a hospital outpatient copay.
Advantage plan costs include premiums, deductibles, copays, and coinsurance. These costs vary among plans, and a person should check details with their plan provider. This online tool may also be useful in finding out a plan’s costs.
The only Medigap cost is a monthly premium, which differs among plans. A person should check with their plan for the costs.
Medicare has several criteria for coverage of wounds and dressings, including: wounds treated by or caused by a surgical procedure, and wounds that need debridement, which is the removal of unhealthy tissue.
Coverage includes both primary and secondary dressings. Primary dressings directly cover the wound, such as foam or hydrogel dressings. Secondary dressings secure a primary dressing and can be gauze, bandages, or adhesive tape.
Medicare also requires a written, signed, and dated order from a doctor. The order must specify the type, size, frequency, and expected duration of the dressing.
In addition, there must be initial documentation of the need for wound dressings, as well as periodic wound evaluations to show any continued need.
Wounds that need dressing generally involve damage to the skin. The damage may also extend to structures under the skin.
Causes of wounds can include:
- pressure ulcers (bedsores)
- diabetic foot ulcers
- venous leg ulcers
While millions of people in the United States get wounds, older adults may have a higher risk of developing wounds. Poor circulation, immobility, and a higher prevalence of chronic conditions such as diabetes associated with aging may increase the likelihood of skin breakdown and slower healing.
Regardless of the cause, wounds need proper care to prevent infection and promote healing.
In an exam, a member of the healthcare team takes a person’s medical history to gather information that may have a bearing on the wound. This includes medications, diet, and the reason they are seeking treatment.
The exam involves a visual inspection of the wound and may include blood tests and X-rays.
The team then cleans the wound and may debride it. It is then dressed and the person is given instructions on how to care for the wound.
A doctor will then create a treatment plan to address any underlying conditions contributing to the wound. The plan may include physical therapy, pain management, compression stockings, and other therapeutic procedures.
If a person has a pressure sore, it is very important they change their position often. In addition, the American Cancer Society recommends the following practices to aid wound healing:
- Keep the dressing clean and dry, and follow the doctor’s instructions for care.
- Wash hands before changing a dressing, and do not reuse a dressing.
- Never put tape directly on the skin.
- Do not scratch or rub the wound.
- Follow directions in taking prescribed medications, such as antibiotics.
Doctors also advise following a healthy diet that provides vitamins, minerals, proteins, and other nutrients that promote wound healing. Such a diet generally means eating citrus fruits, green, leafy vegetables, fish, eggs, whole grains, and meat.
Original Medicare (Part A and Part B) generally covers wound care and supplies, although there may be out-of-pocket costs.
Medicare Advantage (Part C) also covers wound supplies and care, but the costs are not the same as those associated with Part B.
Medicare supplement plans (Medigap) policies may help pay out-of-pocket costs related to wound care.
Wounds from different causes may require different treatment. A doctor can create a treatment plan to address any health conditions that may be causing or worsening the wounds.