Does Medicare Pay for Ambulance Transportation?

Medicare helps individuals manage healthcare expenses, particularly for unexpected and costly services like ambulance transportation. Understanding Medicare coverage for these services helps beneficiaries navigate their healthcare journey and financial responsibilities.

When Medicare Covers Ambulance Services

Medicare Part B covers ambulance services when medically necessary. This means a patient’s medical condition is so severe that transport by other means could endanger their health, or they are bed-confined and require specialized transportation. The trip must be to receive a Medicare-covered service or to return after receiving care.

Emergency ambulance services are covered when a sudden medical emergency requires immediate medical attention, and an ambulance is the fastest, safest way to reach a medical facility. Examples include heart attack, stroke, or severe bleeding. Medicare typically covers transport to the nearest appropriate hospital or skilled nursing facility.

Non-emergency ambulance services may also be covered, but under stricter conditions. Coverage typically requires a written order from a doctor stating medical necessity. This often applies if a patient is bed-confined (unable to walk or sit in a wheelchair) or requires medical services during the trip only available in an ambulance setting, such as monitoring or intravenous medication. For scheduled non-emergency transports, such as to a dialysis center, prior authorization may be required.

Medicare covers both ground and air ambulance services. Air ambulance (fixed-wing aircraft and helicopters) is covered only when ground transportation is unsuitable due to factors like distance, traffic, or a patient’s severe medical condition preventing safe ground travel. The medical necessity bar for air transport is higher, reserved for situations where immediate and rapid transport is essential and ground options are inadequate.

Medicare primarily covers ambulance transport to hospitals, skilled nursing facilities, or dialysis facilities. Transport to a doctor’s office or home is generally not covered unless specific medical conditions are met and it is medically necessary. Medicare covers transport only to the nearest appropriate facility; if a patient chooses a farther facility, they may be responsible for the difference in cost.

Several situations typically fall outside of Medicare coverage. These include transportation not medically necessary, such as for convenience, or when a patient could safely use other means of transport like a car or taxi. Medicare does not cover ambulette services, which are non-emergency wheelchair-accessible van transports. If transport is to a non-covered facility when a covered one is closer, Medicare may not pay for the full distance.

Understanding Your Costs

When Medicare covers ambulance services, beneficiaries generally have financial responsibilities. Medicare Part B covers emergency and certain non-emergency ambulance services. You must first meet your annual Part B deductible before Medicare begins to pay for services.

After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount for ambulance services. The patient is responsible for the remaining 20% coinsurance. This coinsurance applies to both emergency and non-emergency transports.

Ambulance service providers are required to accept “assignment,” meaning they agree to accept the Medicare-approved amount as full payment. Balance billing, where a provider charges more than the Medicare-approved amount, is generally not permitted for Medicare-covered ambulance services.

Supplemental insurance, such as Medigap policies, can help cover out-of-pocket costs for Medicare-covered ambulance services. Many Medigap plans cover the Part B deductible and the 20% coinsurance. Medicare Advantage plans also cover emergency ambulance services, but they may have different copayments and cost-sharing structures than Original Medicare.

What Happens If Coverage Is Denied

If Medicare denies coverage for an ambulance service, you will receive a notice. For Original Medicare, this is a Medicare Summary Notice (MSN), which details what the provider billed, the Medicare-approved amount, how much Medicare paid, and what you may owe. If you have a Medicare Advantage plan, you will receive an Explanation of Benefits (EOB), which serves a similar purpose.

The denial notice will provide instructions on how to initiate an appeal. Review this document carefully to understand the denial reason and the steps to dispute it. Generally, you have 120 days from the date you receive the MSN to file a Redetermination, which is the first level of appeal.

To strengthen your appeal, gather all relevant medical documentation. This may include doctor’s notes, medical records confirming your condition, and the ambulance transport run-sheet. This information helps demonstrate why other forms of transportation were unsafe or why specialized medical services were required during transit.

Appeals can typically be submitted by mailing a written request and supporting documents to the address provided on your denial notice. Some Medicare Administrative Contractors (MACs) may offer online portals for electronic submission. Keep copies of all documents sent for your records.

If the initial Redetermination is unfavorable, you can pursue further appeal levels. The next step is typically a Reconsideration by a Qualified Independent Contractor (QIC). If still denied, you can request a hearing before an Administrative Law Judge (ALJ), followed by a review by the Medicare Appeals Council, and finally, judicial review in federal district court if certain financial thresholds are met. Each level has specific timeframes and procedures.