Does Medicare Part A Cover Ambulance?

Medicare is a federal health insurance program primarily serving individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease (ESRD). It helps manage healthcare costs, covering services from hospital stays to preventive care.

Ambulance Coverage Under Medicare Part A

Medicare Part A, known as Hospital Insurance, provides coverage for inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Ambulance services are rarely covered under Part A, only in specific and limited situations. This typically occurs when a patient is transferred by ambulance from one facility to another, such as from a hospital to a skilled nursing facility, and the transfer is a medically necessary part of a covered inpatient stay. The transport must be between Medicare-certified facilities, and it must be documented that other means of transportation would endanger the patient’s health.

Ambulance Coverage Under Medicare Part B

Medicare Part B, or Medical Insurance, is the primary component of Original Medicare that covers medically necessary ambulance transportation when a patient’s health condition is such that transport by any other means could endanger their health. This includes transportation to a hospital, skilled nursing facility, or dialysis center. For instance, if a patient is experiencing a heart attack, is unresponsive, or is bleeding heavily, ambulance transport would generally be covered.

Part B covers both emergency and non-emergency ambulance services. Emergency services are covered when a condition requires immediate medical attention and an ambulance is the safest and fastest way to reach a medical facility. Non-emergency ambulance services may also be covered, but they require a doctor’s written order stating medical necessity. This could apply to situations where a patient is bed-confined and unable to sit in a chair or walk, or requires medical services during transit that are only available in an ambulance setting, such as monitoring or intravenous medication. Both ground and air ambulance services can be covered if ground transport is not feasible due to distance, traffic, or the patient’s critical condition.

Patient Costs for Ambulance Services

Beneficiaries are responsible for a portion of ambulance costs under Medicare Part B. After the annual Part B deductible is met, Medicare typically pays 80% of the Medicare-approved amount for ambulance services. The beneficiary is then responsible for the remaining 20% coinsurance.

For 2025, the annual Medicare Part B deductible is $257. This amount must be paid out-of-pocket before Medicare coverage begins. Most ambulance companies that contract with Medicare are required to accept Medicare assignment, meaning they accept the Medicare-approved amount as payment in full and can only bill the beneficiary for the deductible and coinsurance. If an ambulance company 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.

Medical Necessity and Coverage Denials

Medical necessity is a key determinant for Medicare ambulance coverage, meaning the patient’s condition is such that using any other method of transportation would endanger their health. This is not simply about convenience but about the safety and well-being of the patient, considering factors like the need for medical monitoring, medical procedures en route, or the risk of deterioration. A physician’s order can support medical necessity for non-emergency transport, but the ultimate determination rests on whether other transport options were contraindicated.

Coverage for ambulance services can be denied for several reasons. Common denials occur if the transport is not medically necessary, if the patient could have been safely transported by other means, or if the ambulance takes the patient to a facility farther than the nearest appropriate one. Additionally, issues such as incomplete documentation from the ambulance company or a lack of proper authorization for non-emergency services can lead to denials. If a claim is denied, beneficiaries have the right to appeal the decision. The appeals process involves several levels. It is important to review the Medicare Summary Notice (MSN) for denial reasons and follow the instructions for filing an appeal, often within 120 days of the denial notice. Providing supporting documentation, such as a letter from the treating physician explaining the medical necessity, can strengthen an appeal.