Does Medicare Cover Ambulance Bills?

Understanding how Medicare covers ambulance services is important, whether for emergency transport or specific non-emergency situations. Medicare can cover ambulance bills, but this coverage is subject to specific conditions and requirements.

Understanding Medicare Coverage for Ambulance Services

Medicare Part B generally covers ambulance services when they are considered medically necessary. A service is deemed medically necessary if your health would be endangered if you were transported by any other means. This applies to both emergency and certain non-emergency situations.

For emergency ambulance services, Medicare covers transportation when your health is in serious danger and immediate medical attention is required. Ground transportation must be the fastest and safest option. The ambulance must transport you to the nearest appropriate medical facility that can provide the necessary care.

Non-emergency ambulance transportation can also be covered if a doctor provides a written order stating it is medically necessary. This might apply if you are confined to bed and cannot be moved by other means, or if you need medical services during transport. An example is regular transport for dialysis treatment for individuals with end-stage renal disease.

Medicare also covers air ambulance services, including helicopters or fixed-wing aircraft, but only under stricter conditions. Air transport is covered if your medical condition requires immediate and rapid transportation that a ground ambulance cannot provide, or if your location is not easily accessible by ground transport. For all covered services, the ambulance company must be approved by Medicare.

Your Financial Responsibility for Ambulance Bills

Even when Medicare covers ambulance services, you will typically have some out-of-pocket costs. These costs primarily fall under Medicare Part B. You are responsible for paying the annual Medicare Part B deductible before Medicare begins to pay its share for covered services.

After meeting the deductible, you are generally responsible for a 20% coinsurance of the Medicare-approved amount for the ambulance service. This coinsurance applies to both emergency and non-emergency ambulance services.

Medicare typically only pays for transport to the nearest appropriate medical facility. If you choose to be transported to a facility farther away, Medicare will only cover the cost up to what it would have paid for the nearest facility. You may be responsible for additional mileage charges. If a service is deemed not medically necessary, Medicare may not cover it, leaving you responsible for the full bill. Ambulance companies are generally required to accept Medicare’s approved payment as full payment for covered services.

What to Do if Your Ambulance Claim is Denied

You have the right to appeal Medicare’s decision if your ambulance claim is denied. The process begins with reviewing your Medicare Summary Notice (MSN). This statement details the services billed to Medicare, the amount Medicare paid, and your financial responsibility. The MSN provides the reason for any denial and includes instructions on how to appeal.

The Medicare appeals process has five levels. The first level is a Redetermination, an initial review conducted by a Medicare Administrative Contractor (MAC). You can request a redetermination by following the instructions in the notice. Gather supporting documentation, such as a letter from your physician explaining the medical necessity of the transport, and submit it with your appeal.

If the Redetermination is unfavorable, you can proceed to the second level, a Reconsideration by a Qualified Independent Contractor (QIC). If the QIC’s decision is unfavorable, you may request a hearing before an Administrative Law Judge (ALJ) at the third level. Further appeal levels include a review by the Medicare Appeals Council and judicial review in federal court.

How Other Insurance Affects Ambulance Coverage

Several types of insurance can work alongside Medicare to help cover ambulance bills. Medigap, or Medicare Supplement Insurance, helps pay for out-of-pocket costs not covered by Original Medicare. Many Medigap plans cover the Medicare Part B deductible and the 20% coinsurance for ambulance services, potentially reducing your financial responsibility.

Medicare Advantage Plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. These plans must cover at least the same services as Original Medicare, including medically necessary ambulance services. However, Medicare Advantage plans may have different cost-sharing rules, such as specific copayments for ambulance rides, and might have network restrictions for non-emergency transport.

Medicaid, a joint federal and state program, can also provide assistance for eligible individuals with limited income and resources. Medicaid often covers Medicare deductibles, coinsurance, and copayments, including those for ambulance services, for beneficiaries who qualify for both programs. In situations where you have other primary health insurance, that insurance may pay before Medicare, affecting the coordination of benefits for ambulance services.