Does Medicare Cover Ambulance Transport to a Hospital?

Medicare is a federal health insurance program that provides coverage for millions of Americans, primarily those aged 65 or older, and some younger individuals with disabilities. It offers various benefits designed to help manage healthcare expenses. Among the services covered, medical transportation, such as ambulance services, plays a role in ensuring beneficiaries receive necessary care.

When Medicare Covers Ambulance Transport to a Hospital

Medicare Part B covers ambulance transportation when it is medically necessary. This means a person’s health condition requires immediate medical attention, and transport by other means, such as a car or taxi, would endanger their health.

The “nearest appropriate facility” rule applies to ambulance coverage. Medicare covers transportation to the closest hospital or skilled nursing facility equipped to provide the required level of care for the patient’s condition. If a beneficiary chooses to go to a facility farther away, Medicare may only cover the cost up to what it would have paid for transport to the nearest appropriate facility.

Both emergency and non-emergency ambulance services can be covered under specific criteria. For emergency transport, the situation must pose a serious threat to health, such as severe bleeding, unconsciousness, or a heart attack. Non-emergency ambulance services may be covered if a doctor provides a written order stating that ambulance transportation is medically necessary due to the patient’s condition, making other transport methods unsafe. This can include regular trips for services like dialysis for individuals with end-stage renal disease. Air ambulance services are covered only in limited situations where ground transport is not feasible or safe due to distance, obstacles, or the severity of the patient’s condition.

Understanding Your Costs for Ambulance Services

Ambulance services covered by Medicare Part B involve specific financial responsibilities for the beneficiary. After meeting the annual Part B deductible, Medicare pays 80% of the Medicare-approved amount for medically necessary ambulance services. The beneficiary is then responsible for the remaining 20% coinsurance. For instance, if the Part B deductible has been met, and the Medicare-approved amount for an ambulance trip is $1,200, the beneficiary would pay $240, which is 20% of the approved amount.

The ambulance provider’s acceptance of Medicare assignment affects out-of-pocket costs. If an ambulance company accepts Medicare assignment, they agree to accept the Medicare-approved amount as full payment and cannot charge the beneficiary more than the deductible and coinsurance. However, if a provider does not accept assignment, they may charge more than the Medicare-approved amount, and the beneficiary would be responsible for the difference, in addition to the coinsurance and deductible.

Supplemental insurance, such as Medigap policies or Medicare Advantage (Part C) plans, can help cover these out-of-pocket costs. Medigap plans cover the 20% Part B coinsurance, and some plans may also cover the Part B deductible. Medicare Advantage plans cover ambulance services to the same extent as Original Medicare, but their cost-sharing structure, including copayments, may vary, and some plans may have network restrictions for non-emergency transport.

What to Do If Your Ambulance Claim is Denied

Ambulance claims may be denied by Medicare for several reasons. Common denials occur if the service is deemed not medically necessary, if the transport was to a facility farther than the closest appropriate one without medical justification, or due to paperwork errors or incomplete documentation from the ambulance company.

If an ambulance claim is denied, beneficiaries have the right to appeal the decision. The Medicare appeals process involves several levels. The first step is a “Redetermination,” which must be requested within 120 days of receiving the Medicare Summary Notice (MSN). It is helpful to submit a written explanation of why the transport was medically necessary and include supporting documentation, such as a statement from the treating physician.

If the Redetermination is unfavorable, the next level is a “Reconsideration,” which must be requested within 180 days of the Redetermination decision. Further appeals can proceed to an Administrative Law Judge (ALJ) hearing and then to the Medicare Appeals Council if the previous levels do not resolve the issue. Throughout this process, it is important to keep copies of all submitted documents and correspondence, and to understand the specific reason for the denial.