Understanding Medicare Advantage (Part C) coverage for advanced wound care treatments, networks, and authorization requirements.
Medicare Advantage (Part C) is private insurance that replaces Original Medicare (Parts A & B). All Medicare Advantage plans must cover everything Original Medicare covers—including wound care services. However, the rules differ significantly. Understanding these differences ensures you get the care you need without surprise costs.
Medicare Advantage plans must cover all services Original Medicare covers, including: mobile wound care visits, wound debridement, negative pressure wound therapy (NPWT), advanced biologic dressings, skin substitutes and amniotic grafts, wound cultures, vascular assessments, and offloading devices. The difference is HOW they cover it—copays instead of coinsurance, network restrictions, and authorization requirements.
Most Medicare Advantage plans require prior authorization for:
Healix360 handles all prior authorization paperwork and follows up with your plan to ensure approval before starting treatment.
HMO plans: Must use in-network providers only (except emergencies). Require referrals from primary care physician. PPO plans: Can see out-of-network providers but pay higher copays. May not need referrals. EPO plans: Must use network providers, but usually no referrals needed. Before starting wound care, verify Healix360 is in your plan's network or understand out-of-network costs.
Medicare Advantage uses copays ($20-50 per specialist visit typical) instead of the 20% coinsurance of Original Medicare. While copays seem simpler, they can add up if you need frequent visits. The advantage: out-of-pocket maximum protection. Once you hit your plan's annual limit ($3,000-8,000 typical), the plan pays 100%. Original Medicare has no out-of-pocket maximum.