If you have Original Medicare, your ground ambulance ride is most likely covered. However, there are some limitations on medical transports, and you’ll probably have some out-of-pocket expenses after your ride. Here are more details about what ambulance services are and aren’t covered by Medicare.
What Ambulance Services Does Medicare Cover?
Under Original Medicare, only Medicare Part B covers ambulance transport in emergencies when it’s unsafe to transport you in a different type of vehicle. While Medicare Advantage and other Medicare plans should provide ambulance services, cost, rules, and coverages vary by plan. Here’s a look at some common types of ambulance services, so you can see what kinds of emergency transportation Medicare covers.
Emergency Ambulance Transport
Medicare Medical Insurance, or Part B, typically covers standard ground ambulance transport for emergencies. This coverage allows you to be transported to a hospital, critical access hospital, or skilled nursing facility for medically necessary services. Medicare takes the seriousness of your medical condition into account before paying the bill. If you could have safely been taken to the hospital by car or taxi, your costs might not be covered. So, if you cut yourself and are bleeding profusely, Medicare will likely approve your emergency transport. When you’re losing a lot of blood, it’s a medical emergency, and you need to get to the hospital as quickly as possible. However, if you fall and injure your knee, it’s possibly you could get to the hospital on your own. In this case, if the ambulance wasn’t medically necessary, it probably wouldn’t be covered by Medicare.
Emergency Air Transport
In certain situations, Medicare may pay for emergency air transport. However, this type of emergency transportation only gets approved if certain criteria are met. First, your health must require immediate transport that can’t be provided by ground transport. Then, at least one of these conditions must be met: For instance, if you’re hiking in a remote location and fall off the edge of a cliff and have internal bleeding, your air transport might be covered. In this case, you’re in a spot where a ground ambulance can’t easily get to you. In addition, your health condition is serious enough to require critical care quickly.
Some Non-Emergency Transport
Typically, Medicare only covers ambulance services for emergency transport. However, there are particular circumstances when non-emergency transportation is allowed. To have non-emergency transport covered, the following conditions must be met:
Your doctor must write an order for the ambulance transport. You have a medically necessary reason to use an ambulance instead of a different type of vehicle.
Someone with end-stage renal disease who must be transported to a dialysis center by stretcher is one example of when non-emergency transport may be approved. Another is for a patient with severe obesity who cannot safely be transported in a car or van. In Delaware, District of Columbia, Maryland, North Carolina, New Jersey, Pennsylvania, South Carolina, Virginia, and West Virginia, patients who schedule three non-emergency ambulance transports in a 10-day period must have prior authorization before the fourth trip. If prior approval isn’t granted and you continue using ambulance transport for non-emergency situations, Medicare denies the claim and you’ll be responsible for the bills. If the ambulance crew doesn’t believe Medicare is going to cover your transportation because it’s not an emergency, they must give you an Advance Beneficiary Notice of Noncoverage (ABN) to charge you for the ride. This form typically has option boxes that allow you to check if you want the service. The form also explains your payment responsibility if you opt for the transport knowing Medicare may not cover it. If you sign, you must pay the bill if Medicare denies the claim.
How Much Does Medicare Cover?
If Medicare approves your ambulance transport claim, it covers 80% of the Medicare-approved amount, leaving you responsible for the other 20%. The Medicare-approved amount is a fee schedule that varies based on your location. However, ambulance transport counts toward your annual Part B deductible. So, if you haven’t yet met your deductible, you’re responsible for paying the remaining amount plus the standard 20% coinsurance. Many Medigap (Medicare Supplement Insurance) policies can help pick up the tab left behind by your Original Medicare copayments and deductibles. Compare plans and benefits on Medicare.gov.
Original Medicare vs. Medicare Advantage Ambulance Coverage
Original Medicare is Medicare Parts A and B. But some people opt for a Medicare Advantage (Medicare Part C) as a way to receive their Part A and B benefits. If you have a Medicare Advantage Plan, it’s important to note that while your plan has the same basic benefits, each plan has its own rules and many have in- and out-of-network providers. To make sure you don’t get hit with unexpected ambulance bills, make sure you read your plan materials or call your plan to discuss its expenses.
How To Dispute a Denial of Coverage
If Medicare denies your ambulance transport coverage and you think it should have been approved, there are some steps you can take: Review your copies of the claim paperwork, as there may be procedural errors that could be corrected. For instance, the ambulance company didn’t file the right form or didn’t fully record why ambulance transport was necessary. Once the ambulance company corrects these errors, ask it to resubmit the claim to Medicare. File an appeal if your claim still gets denied. Appeals are part of your rights. To start the appeal process, review the Medicare Summary Notice (MSN) to gather more information about this claim. You’ll see on this form how long you have to file an appeal and what steps you need to take to do so. Then follow the directions on the MSN and submit it along with a letter explaining why you think the service should be covered.
