Does Medicare Cover the Cost of an Ambulance?

Medicare Part B typically covers ambulance transportation when it is medically necessary, meaning a person’s health condition requires professional medical care during transport. This coverage extends to situations where other transportation methods could endanger a person’s health. This article clarifies the specific conditions for Medicare coverage and outlines potential financial responsibilities.

General Rules for Coverage

Medicare Part B covers ambulance services when medically necessary and reasonable for a beneficiary’s condition. Medical necessity means the individual’s health status requires ambulance transport because other means would jeopardize their health. For instance, if a person cannot be safely transported by car or wheelchair due to their medical condition, an ambulance may be considered medically necessary. The ambulance service must be provided by a Medicare-approved supplier, and the transport must be to the nearest appropriate medical facility capable of providing the required care.

Medicare assesses medical necessity based on the patient’s condition at the time of transport. The service must be for a Medicare-covered service or to return from receiving care.

Specific Conditions for Ambulance Transport

Medicare provides coverage for both emergency and non-emergency ambulance services, each with distinct criteria for medical necessity. Emergency services are covered when a sudden medical event, such as a heart attack, stroke, or severe injury, requires immediate transport to the nearest appropriate medical facility. This is necessary when the patient’s condition is life-threatening and cannot be safely managed by other transportation methods.

Non-emergency ambulance services can also be covered, but they are subject to stricter conditions. These services, often for scheduled appointments like dialysis or chemotherapy, require a physician’s order stating that ambulance transport is medically necessary. The order must certify that the patient’s condition prevents safe transport by other means, such as being bed-confined or requiring vital medical services during the trip. For repetitive, scheduled non-emergency transports, prior authorization may be required, which helps ensure compliance with Medicare rules before services are rendered.

Both ground and air ambulance services can be covered if medically necessary. While ground ambulance is typically the primary mode, air ambulance (helicopter or airplane) is covered in situations where ground transport is not feasible due to distance, terrain, or if the patient’s condition demands rapid transport that ground transport cannot provide. Air ambulance is specifically reserved for critical situations where the time saved or the specialized care available during air transport is essential for the patient’s survival or to prevent serious health deterioration.

Your Financial Responsibility

Even when Medicare covers ambulance services, beneficiaries typically incur out-of-pocket costs. Ambulance services fall under Medicare Part B, meaning the annual Part B deductible must be met before Medicare begins to pay. For 2025, the annual Medicare Part B deductible is $257.

After the deductible is satisfied, Medicare generally pays 80% of the Medicare-approved amount for the ambulance service. The beneficiary is responsible for the remaining 20% coinsurance. The ambulance service provider should accept “assignment,” meaning they agree to accept the Medicare-approved amount as full payment. If a provider does not accept assignment, the beneficiary might be responsible for a higher charge. If Medicare determines the service was not medically necessary, the beneficiary may be responsible for the full cost of the ambulance transport.

What to Do if Coverage is Denied

If Medicare denies coverage for an ambulance service, the first step is to review the “Medicare Summary Notice” (MSN). This document provides details on what Medicare paid and the specific reasons for any denial. Understanding the denial reason is important before initiating an appeal.

The initial appeal is called a “redetermination” and must be requested from Medicare’s claims administrator within 120 days of receiving the MSN. When filing, it is crucial to submit any supporting documentation, such as medical records or a physician’s statement, that substantiates the medical necessity of the ambulance service.

If the redetermination is unfavorable, further levels of appeal are available. The next step is a “reconsideration” by a Qualified Independent Contractor (QIC), which typically has a 180-day filing deadline from the redetermination decision. Should the QIC’s decision also be unfavorable, a beneficiary can request a hearing before an Administrative Law Judge (ALJ), generally within 60 days. Subsequent appeal levels include review by the Medicare Appeals Council and, finally, judicial review in a federal district court, provided the claim meets a minimum dollar amount in controversy.