Medicare Coverage for Ambulance Services

What Is and Is Not Covered

If you have ever paid for an ambulance ride, you know it doesn't come cheap. Costs can range from hundreds to thousands of dollars. Some companies will tack on additional charges for additional practitioners on board (i.e., critical care nurses, respiratory therapists, etc.), use of medical supplies (i.e., oxygen masks, bandages, dressings, ice packs, etc.), and mileage among other things.

The question is whether or not your insurance plan will pay for ambulance services when you need them. Medicare will but only sometimes. Even in covered situations, Medicare Part B will only pay 80%, leaving you with the rest.

Ambulance on an avenue

 

Mario Gutiérrez / Getty Images

Medicare Coverage for Emergency Situations

An ambulance, in Medicare's eyes, is only indicated if there is no other safe means of transportation, you are being transported to receive medically-necessary care that is covered by Medicare, and the ambulance company accepts the assignment.

Keep in mind an ambulance can be a medically-equipped van but it can also be an airplane or helicopter. Emergency transportation by air may be covered if your pick-up location cannot be reached by ground transportation or if obstacles with ground transportation (i.e, heavy traffic) would delay your ability to access emergency care.

In a medical emergency, your health is at stake. Medicare will pay for ambulance services to the nearest medical facility that can offer the appropriate level of care. You cannot pick and choose which facility you want to go. Otherwise, expect to pay the full cost of the ambulance ride out of your own pocket.

For example, if you were having chest pain, you may need to have cardiac catheterization. If the closest hospital does not offer that service, Medicare will pay for the ambulance to drive you to the closest hospital that does.

In 2020, Medicare will pilot a program, the Emergency Triage, Treat, and Transport (ET3) Model, which allows first responders to transport people to facilities other than emergency rooms and hospitals. Based on the severity of their triage findings, a first responder may be able to transport people with acute medical needs to doctor's offices or urgent care clinics instead. This may allow decrease health care costs for people who may need medical help but not in a hospital setting. Not all ambulance companies will be included in the pilot.

Medicare Coverage for Non-Emergency Situations

For Medicare to approve coverage in non-emergency situations, certain conditions must be met. You must require transportation to receive medical evaluation and/or treatment; you are confined to your bed and cannot travel by other means; or you require medical care during the course of transport. Not having another means of transportation is not considered a sufficient reason for Medicare to pay for services.

Common examples of non-emergency situations that may be covered include transportation to get dialysis or transportation from a skilled nursing facility to another facility where you will receive medical care. It is not required that care be administered at a hospital.

Don't assume that Medicare will automatically cover in these situations, however. A doctor's order may be required to prove that the use of the ambulance is medically necessary.

How Medicare Tightens the Reins

Medicare fraud may be more common than you may realize. A 2015 study by the Inspector General of the U.S. Department of Health and Human Services found that the Centers for Medicare and Medicaid overpaid more than $30 million on ambulance services to facilities where Medicare services were not performed and $17 million on transport to and from facilities not covered under the Medicare benefit. In 2018 alone, the U.S. Justice Department convicted a Texas ambulance company for submitting $3 million and a California ambulance company for submitting $1.1 million in fraudulent claims to Medicare.

To decrease misuse of ambulance services, Medicare has trialed a pre-approval process, known as a prior authorization, for non-emergency ambulance services in eight states (Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia) and the District of Columbia. If you use three ambulance rides, either within a 10-day period or once a week over three weeks, Medicare must pre-approve the fourth before you can receive the service again. The idea is to cut back on overuse or inappropriate use of ambulances. This prior authorization requirement will continue through December 1, 2020. At that time, the Centers for Medicare and Medicaid Services may consider expansion across all states.

When Medicare Does Not Cover Your Ambulance Ride

If you think Medicare should have covered your ambulance ride, you may be right. Sometimes the ambulance company does not include all the appropriate documentation when they file a claim with Medicare. Also, check to see if you signed an Advanced Beneficiary Notice of Noncoverage (ABN). This is a form that an ambulance company may ask you to sign if they believe there is a possibility Medicare may not pay for the service. By signing the form, you are accepting responsibility for payment even if Medicare later denies coverage. If you did not sign an ABN, you may be off the hook for paying. This will not apply in all cases but it is worth checking. Regardless, ABN or no ABN, you always have the right to appeal your case to Medicare.

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Article Sources
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  1. Emergency Triage, Treat, and Transport (ET3) Model. Centers for Medicare and Medicaid Services. Updated February 14, 2019.

  2. Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports. U.S. Department of Health and Human Services - Office of the Inspector General. Published September 2015.

  3. Ambulance Company Owner Convicted in $3 Million Medicare Fraud Conspiracy. U.S. Department of Justice. Published August 20, 2018.

  4. Former Employee of Southern California Ambulance Company Sentenced to Prison for Role in Medicare Fraud Scheme. U.S. Department of Justice. Published April 16, 2018.

  5. Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport. Centers for Medicare and Medicaid Services. Updated November 8, 2019.