Although out-of-pocket costs may vary between original Medicare, Medicare Advantage, and Medigap, Medicare generally covers wound care and supplies.
Wounds are breaks in the skin. They can be minor scratches, cuts, or punctures that an individual can clean and dress at home. However, a doctor may need to check and dress more severe wounds in the hospital.
This article examines Medicare coverage of wound care and supplies, out-of-pocket costs, and coverage rules. It also discusses the types of wounds that need dressings, what to expect in a wound exam, and how people can help their wounds heal.
Original Medicare coverage includes Part A hospitalization coverage and Part B medical insurance.
Medicare Part A provides coverage if a person’s wounds require surgery as an inpatient in the hospital. It also covers the care that someone receives in a hospital or skilled nursing facility for a limited number of days. This includes wound care.
Medicare Part B is medical insurance that covers the services of a healthcare professional to dress a wound and the supplies they need for this care. This only applies to care an individual receives in a doctor’s office or another outpatient setting.
Private insurance companies administer Medicare Advantage plans (Medicare Part C), which are the alternative to original Medicare. These bundled plans provide the same level of coverage as parts A and B for wound care and supplies.
There are different types of Medicare Advantage plans. In all of the different types of Advantage plans, a person should always also have coverage for urgent care, which can include treatments such as wound dressings.
Many Advantage plans often provide additional benefits, such as prescription drug coverage and dental care. An individual should check with their plan provider regarding these specific benefits.
Medigap is supplemental insurance that a person with original Medicare can buy. These Medicare supplement plans help people meet out-of-pocket costs associated with parts A and B, such as deductibles, copays, and coinsurance.
Medigap plans may help pay toward costs related to wound care. The amount that individuals pay depends on the plan. For example, Plan K limits costs to $6,220, while plan L has a limit of $3,110.
A person can use this online tool to find a Medigap plan.
If someone needs to stay in a skilled nursing facility because of their wounds, Medicare contributes to these costs for a short period of time.
For the first 21 days of a stay in these facilities, a person will not pay anything out of pocket. From day 21 through day 100, individuals may pay up to $185.50 per day. After 100 days, Medicare will no longer provide coverage.
Another cost that Medicare does not cover is custodial care. If someone’s wounds make it difficult for them to perform activities, such as bathing and dressing, Medicare does not cover the costs of an attendant to provide this care.
Medicare has several criteria for coverage of wounds and dressings. For the program to cover the wound, it must be either a wound treated or caused by a surgical procedure or a wound that needs 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 consist of gauze, bandages, or adhesive tape.
Medicare also requires a written, signed, and dated order from a doctor. This 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, and periodic wound evaluations to show any continued requirements.
The out-of-pocket costs vary between original Medicare parts A and B, Medicare Advantage, and Medigap.
If a person receives wound care while in a hospital, the costs include the following:
- $1,484 deductible for each benefit period
- $0 coinsurance for the first 60 days of each benefit period
- $371 per day coinsurance of days 61–90 of each benefit period
- $742 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 receives wound care in a skilled nursing facility, the coinsurance is:
- $0 for days 1–20 of each benefit period
- $185.50 per day coinsurance of days 21-100 of each benefit period
- all costs after day 101
A benefit period begins 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 a person’s home, the costs fall under Part B. Medicare does not charge for the supplies.
However, expenses for care include:
- $203 annual deductible
- $148.50 monthly premium
- 20% coinsurance
If someone chooses to receive wound care in an outpatient hospital setting instead of a doctor’s office, they may have a hospital outpatient copay.
Advantage plan costs may include different premiums and costs for services. 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. Individuals should check with their plan provider for more information about these costs.
Original Medicare, comprising parts A and B, generally covers wound care and supplies, although there may be out-of-pocket costs.
Medicare Advantage, or 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.