If you have a medical emergencyWhen you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death., Medicare covers transportation to the nearest Medicare-approved facility to care. However, it gets tricky when trying to determine what is and what isn’t an emergency.
If you broke your arm, for instance, an ambulance trip may not be covered by Medicare because you could just as easily be transported in a car. Something like a car accident, a major fall, or a heart attack, however, is typically covered as an emergency for the purposes of an ambulance ride.
Key Takeaways
- Ambulance transportation is an emergency service for transporting people to emergency care facilities.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. covers ambulance transportations for medical emergency situations.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover ambulance transportation, but the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. will have to use services within that plan.
- MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. policies can provide help with ambulance transportation costs after Medicare has provided coverage.
- Medicare Part B will cover non-emergency ambulance transportation if ordered by the patient’s doctor.
- If Medicare coverage for ambulance transportation was denied, you can file an appealAn appeal is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare Part D plan. with proof that it was medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice..
- Ambulance transport costs can vary wildly depending on the area and transportation type needed, with a conservative average of $450 per ground ambulance transport.
What Is Ambulance Transportation?
Ambulance transportation is an emergency vehicle service used to transfer people in critical condition to and between appropriate medical facilities. Ambulance vehicles will include advanced life support systems on the vehicle and are staffed by highly trained emergency medical technicians (EMTs) that keep you stable during your transport. Ambulances can be ground transport vehicles or air transport vehicles such as planes and helicopters to reach people away from roads.1Mayoclinic.org, “Emergency ground transport“, Accessed November 11, 2021
How Does Medicare Cover Ambulance Transportation?
When you need emergency transportation to a Medicare-approved hospital, critical access hospital, or skilled nursing facility for medically necessary services, Medicare Part B covers your ambulance transportation. Additionally, in some instances, Medicare will cover a portion of air transportation to an appropriate medical facility. There are specific criteria to determine if Medicare will help pay for air transport. One of them is if the location you are in can’t be reached by a vehicle. In that case, air transportation would be a covered service. Also, traffic and obstacles that prevent you from getting timely care could be a reason to send an air ambulance and for Medicare to pay for it.2Medicare.gov, “Ambulance services“, Accessed November 11, 2021
Interestingly, Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. does not provide coverage for ambulance transportation. While Part A does cover inpatient careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition. services such as hospitalization, you are not considered an inpatient until you are actually admitted into the facility’s care. Therefore, transportation services leading up to that hospital admittance would be covered by Part B.2Medicare.gov, “Ambulance services“, Accessed November 11, 2021
Medicare Advantage
Medicare Advantage plans, also known as Medicare Part CMedicare Part C is Medicare's private health plan option. Also known as Medicare Advantage, Medicare Part C plans are a type of Medicare health plan offered by companies that contract with Medicare to provide all..., must provide coverage for the same services that Medicare Part A and Part B cover. This means that Medicare Advantage plans will cover ambulance transportation in a medical emergency to the nearest appropriate medical facility that is needed. Your Medicare Advantage plan cannot force you to receive emergency care in a plan-approved facility. However, the out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for ambulance transportation with a Medicare Advantage plan may be different than those with Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. 3Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 10, 2021
Medigap
People with Original Medicare can purchase additional insurance, called Medigap, to help cover their Medicare out-of-pocket costs. Medicare supplement insurance, as it is also known, is available through private insurance companies. A Medigap policy will cover some or all of the out-of-pocket costs associated with Medicare-approved ambulance services. These costs include:4Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 12, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
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Non-Emergency Ambulance Transportation
In general, only emergency ambulance services are covered under Medicare Part B. For non-emergency services, there must be a good medical reason for the need for transport. This medical need must be documented by your attending physician and given to Medicare in advance for pre-approval. Ambulance services for that event would then be covered in part by Medicare. This could be used for instance for a patient with kidney disease in need of transport to and from a dialysis facility.2Medicare.gov, “Ambulance services“, Accessed November 11, 2021
Medicare Coverage Denial
You may be denied coverage for ambulance services if it was for an incident that Medicare does not deem as an emergency. For instance, if you broke your arm and your friend could have driven you to the hospital, you would be slapped with the full bill for calling an ambulance. If you broke your legs from a big fall and no one was nearby to transport you, that ambulance ride would be covered by Medicare. You may also be denied coverage if the ambulance did not transport you to the nearest facility or if they transported you to a facility that does not accept Medicare.2Medicare.gov, “Ambulance services“, Accessed November 11, 2021
Medicare Coverage Appeal
You may appeal if coverage is denied. To do this, you need to fill out the Redetermination Request Form and send it to your Medicare Claims Office’s address. You can find their specific address in your monthly Medicare Summary Notice (MSN), located on the bottom right corner of the fourth page.5Medicare.gov, “How do I file an appeal?“, Accessed November 16, 2021
When filling out your claimA request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered., be explicit about the coverage you were denied and explain the circumstances that justified why calling an ambulance was necessary. It helps to have a physician and other medical professionals and witnesses document why transportation by ambulance was necessary as opposed to other forms of transportation. There are other details about the medical event that would need to be documented.5Medicare.gov, “How do I file an appeal?“, Accessed November 16, 2021
How Much Does Ambulance Transportation Cost?
Ambulance costs can vary wildly between areas and the type of transportation required, with a conservative average of $450 for ground ambulances and over $21,000 average for air ambulance transportation. If the ambulance transportation was confirmed to be medically necessary, Medicare Part B will cover 80 percent of the approved costs once you have paid their annual Part B deductible.6Healthaffairs.org, “Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills“, Accessed November 11, 2021
Summary
You now know how Medicare covers ambulance transportation. If you need an ambulance, you better really need it or the costs may catch you by surprise. If you need transportation for a non-emergency condition, you should get a written prior authorizationPrior authorization is a process used by health plans to control healthcare costs. Most HMO plans and some PPO plans require authorization before receiving certain treatments, medical services, or prescription drugs. from your doctor ready to go in case you need to make an appeal. If you are suffering a medical emergency and you cannot be transported to a hospital safely by a friend, call 911 or your local emergency number to request an ambulance.
Citations
- 1Mayoclinic.org, “Emergency ground transport“, Accessed November 11, 2021
- 2Medicare.gov, “Ambulance services“, Accessed November 11, 2021
- 3Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 10, 2021
- 4Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 12, 2021
- 5Medicare.gov, “How do I file an appeal?“, Accessed November 16, 2021
- 6Healthaffairs.org, “Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills“, Accessed November 11, 2021