Does Medicare Pay for Medical Transport? A Breakdown

Medicare, the federal health insurance program for people aged 65 or older, certain younger people with disabilities, and individuals with End-Stage Renal Disease, provides coverage for a range of medical transport services. This coverage often depends on the type of transport, the medical necessity, and whether the service is emergency or non-emergency.

Ambulance Services and Medicare Coverage

Medicare Part B generally covers ambulance services when transportation is medically necessary. This means a patient’s health would be endangered if transported by other means, such as a car or taxi. The service must be provided by a Medicare-certified provider, and the transport must be to the nearest appropriate medical facility. If a patient chooses to go to a facility farther away for personal preference, Medicare may not cover the additional charges.

For emergency situations, Medicare covers 80% of the approved amount for ground ambulance transportation to the nearest appropriate medical facility. An emergency is defined as a situation where a patient’s health is in serious danger and cannot be transported safely by other means. This includes conditions such as severe injuries or heart attacks.

Non-emergency ambulance services can also be covered by Medicare Part B. A physician’s certification is required, indicating that ambulance transportation is necessary because other means are medically contraindicated. This might apply if a patient is confined to bed, unable to walk, unable to sit in a chair or wheelchair without help, or requires medical services, like medication administration or vital sign monitoring, during transport.

Air ambulance services are covered by Medicare Part B in limited circumstances. Coverage is approved only when ground transportation is not feasible or would endanger the patient’s health due to urgency or geographical barriers. This could include situations where a ground ambulance cannot reach the patient’s location, or if there is significant distance or obstacles like heavy traffic preventing timely arrival at the nearest appropriate facility.

Non-Emergency Medical Transportation Coverage

Medicare’s coverage for non-emergency medical transportation (NEMT) is very limited under Original Medicare. Routine rides to a doctor’s appointment are not covered. However, Medicare may provide coverage if a doctor certifies the trip as medically necessary to protect the patient’s health.

This includes specific situations such as round-trip transportation from a patient’s home or skilled nursing facility to the closest facility providing renal dialysis for individuals with End-Stage Renal Disease. Another instance where NEMT might be covered is for transport to a Medicare-approved facility for specific rehabilitation services, but only if the patient’s medical condition prevents them from using other forms of transportation. Medicare generally does not cover wheelchair van transportation or ambulette services.

Medicare Advantage plans, which are offered by private companies approved by Medicare, may offer additional NEMT benefits that Original Medicare does not. These benefits can include scheduled rides for routine doctor visits or transportation for therapy sessions or prescription pick-ups. The availability and scope of such NEMT benefits vary significantly by plan and location.

Financial Responsibilities and Billing

When Medicare approves coverage for medical transport, beneficiaries have financial responsibilities under Medicare Part B. For 2025, after meeting the annual Part B deductible of $257, beneficiaries are responsible for a 20% coinsurance of the Medicare-approved amount. This coinsurance can represent a significant portion of the total cost, especially for high-cost services like air ambulance, which can range from $12,000 to $25,000 for a 52-mile flight.

Ambulance providers bill Medicare directly for covered services. They must accept assignment, meaning they agree to accept the Medicare-approved amount as full payment. The provider will then bill the beneficiary for any unmet deductible and the 20% coinsurance.

For certain repetitive, scheduled non-emergency ambulance services, prior authorization may be required. This process helps ensure medical necessity is established before services are rendered. If prior authorization is not obtained or denied, and the beneficiary still receives the services, Medicare may deny the claim, making the beneficiary responsible for the full cost. An Advance Beneficiary Notice of Noncoverage (ABN) may be issued by the ambulance provider in non-emergency situations to inform the beneficiary of potential financial responsibility if Medicare is not expected to cover the service.

Appealing a Coverage Denial

If Medicare denies coverage for medical transport, beneficiaries have the right to appeal the decision. The appeal process begins after receiving a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) that details the denial. Beneficiaries have 120 days from the date of the MSN to request a redetermination, which is the first level of appeal.

Gathering supporting documentation is important to strengthen an appeal. This includes obtaining a written statement from the physician who ordered the transport, or the primary care physician, explaining why the transport was medically necessary. Requesting a copy of the transport run-sheet from the ambulance provider and any relevant medical records from the hospital or other inpatient facility can provide further evidence.

If the redetermination is unfavorable, the beneficiary can proceed to the second level of appeal, known as reconsideration. Instructions for requesting a reconsideration are provided with the redetermination decision, and beneficiaries have 180 days to submit this request. Should the reconsideration also result in an unfavorable decision, further appeal levels, such as a hearing with an Administrative Law Judge (ALJ), may be pursued.