Does Medicare Cover 911 Ambulance Services?

Medicare is a federal health insurance program for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. This article explains how Medicare covers ambulance transportation, focusing on emergency 911 services, to help beneficiaries understand their coverage.

Medicare Part B Coverage for Emergency Ambulance Services

Medicare Part B provides coverage for emergency ambulance services when transportation is medically necessary. This means that the patient’s health condition requires immediate medical attention, and using any other method of transportation could endanger their health. Ground ambulance services are typically covered to the nearest appropriate medical facility, such as a hospital or skilled nursing facility, that is equipped to provide the necessary level and type of care.

Medical necessity for emergency ambulance transport is established when the patient’s condition is such that alternative transportation methods are not suitable. For instance, situations involving severe injury, sudden illness like a heart attack, stroke symptoms, or uncontrollable bleeding often warrant emergency ambulance use. The ambulance service provider plays a role in determining this medical necessity, and their documentation supports the claim for coverage.

Air ambulance services, including both fixed-wing aircraft and helicopters, are also covered under Medicare Part B in specific emergency situations. This coverage applies when ground transportation is medically inappropriate, such as when the patient’s condition requires rapid transport over long distances, or when ground obstacles prevent timely arrival at a facility. Air ambulance transport is approved if it is the only safe way to transport a patient to the nearest hospital capable of providing the required specialized treatment, such as for severe trauma, extensive burns, or conditions requiring neurosurgical intervention.

Medicare Coverage for Non-Emergency Ambulance Services

Medicare may also cover non-emergency ambulance transportation, but the conditions for coverage are more stringent compared to emergency services. Non-emergency ambulance services involve scheduled transport for medically necessary services, such as transfers between facilities or regular trips for treatments like dialysis. Coverage for these services is granted if other transportation methods are not medically appropriate due to the patient’s condition.

For non-emergency ambulance transport to be covered, it must be medically necessary, meaning the patient’s health would be jeopardized if they were transported by any other means. A physician’s order certifying this medical necessity is typically required, often obtained by the ambulance supplier within a specified timeframe. For repetitive scheduled non-emergency transports, prior authorization from Medicare is frequently required, ensuring that the services comply with coverage rules before they are provided.

Examples of situations where non-emergency transport might be covered include a patient who is bed-bound and unable to move without assistance, or an individual requiring medical supervision or specific medical services during transit that only an ambulance can provide. However, Medicare generally does not cover non-emergency ambulance services if the transport is for convenience, or if the patient could safely use other transportation options like a wheelchair van or a car, even if those options are unavailable to the patient. Prior authorization for repetitive scheduled non-emergency ambulance transports (RSNAT) can affirm a specified number of trips, such as up to 40 round trips within a 60-day period, and can be extended for chronic conditions.

Understanding Your Financial Responsibility and Appeals

Even when Medicare covers ambulance services, beneficiaries have financial responsibilities. For services covered under Medicare Part B, individuals are responsible for the annual Part B deductible. After the deductible is satisfied, beneficiaries pay 20% of the Medicare-approved amount for the ambulance service as coinsurance. For instance, in 2025, the Medicare Part B deductible is $257.

Ambulance service providers that accept Medicare assignment agree to accept the Medicare-approved amount as full payment, billing only for the deductible and coinsurance. If a provider believes Medicare may not cover a service, they should issue an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. Signing an ABN means the beneficiary agrees to be financially responsible if Medicare denies payment. Refusing to sign may lead to the provider not rendering the service, or the beneficiary becoming responsible for the full cost.

Should a claim for ambulance services be denied, beneficiaries have the right to appeal the decision through a multi-level process. The first step is to request a “Redetermination” from the Medicare Administrative Contractor (MAC) within 120 days of receiving the Medicare Summary Notice (MSN) detailing the denial. This request can be made by completing Form CMS-20027 or submitting a written statement explaining disagreement with the initial determination. The MAC issues a decision within 60 days.

If the redetermination is unfavorable, the next level is a “Reconsideration” by a Qualified Independent Contractor (QIC). This request must be filed within 180 days from the date of the redetermination decision. The QIC conducts an independent review of the administrative record and issues a decision within 60 days. Should the QIC’s decision also be unfavorable, the beneficiary can request a hearing before an Administrative Law Judge (ALJ). This third-level appeal requires the amount in controversy to meet a minimum dollar threshold, which for 2025 is $190.

Further appeal levels exist if the ALJ’s decision is unsatisfactory. The fourth level involves a review by the Medicare Appeals Council, which must be requested within 60 days of the ALJ’s decision. If still dissatisfied with the Appeals Council’s decision, beneficiaries can seek “Judicial Review” in a Federal District Court. This fifth level has a minimum amount in controversy requirement, which for 2025 is $1,900. Throughout the appeals process, maintaining thorough documentation, including medical records, physician’s orders, and any ABNs, is important to support the claim.