People want to know why Medicare didn’t pay for a trip to a local emergency department or to a hospital on the other side of town. It’s good to keep in mind that Medicare covers ambulance trips only when they’re medically necessary and reasonable. What does that mean?
If a car or taxi could transport you without endangering your health, Medicare won’t pay. Medicare probably won’t pay, for example, for an ambulance to take someone with a simple fracture in her ankle to a hospital. But if she goes into shock, or is prone to internal bleeding, ambulance transport may be medically necessary to ensure the patient’s safety on the way. The details make a difference.
It also means that the facility must have a physician or physician specialist available to treat your condition. Thus, Medicare may pay for an ambulance to take you to a more distant hospital if, for example, you are seriously burned and the hospital has a special burn unit. Similarly, if you live in a rural area where the nearest hospital equipped to treat you is a three-hour drive away, Medicare will pay. But if you want an ambulance to take you to a more distant hospital simply because the doctor you prefer has staff privileges there, expect to pay a greater share of the bill. Medicare will cover the cost of ambulance transport to the nearest appropriate facility and no more.
Ambulances and their crews must meet staffing and medical equipment rules to qualify for Medicare payment. Medicare does not cover transport in wheelchair vans.
Medicare covers medically necessary ambulance trips in emergencies and, in certain limited cases, non-emergencies where the person is bed-confined or has an acute medical condition that requires medical supervision or treatment during in transit. Emergencies include, for example, when you’re in shock, unconscious, or bleeding heavily.
Medicare covers medically necessary ambulance trips only to certain destinations. They are hospitals, critical access hospitals in rural areas, skilled nursing facilities, dialysis facilities, and your home. In rare cases, Medicare also pays for stops at a physician’s office on the way to an appropriate facility. As a general rule, Medicare only covers local ambulance transportation.
Medicare Part B pays 80% of an approved amount for ambulance trips. You’re responsible for 20% of the approved amount (the coinsurance charge). Ambulance companies must submit their bills directly to Medicare and accept assignment. This means they take Medicare’s approved amount as full payment. If you have insurance to cover the Part B coinsurance charge, you should owe nothing out-of-pocket for Medicare-covered ambulance trips.
As noted, Medicare won’t cover ambulance services when it decides the trip was not necessary or appropriate. Often, a lack of information about a person’s condition or need for services leads to denials. People with Medicare have appeal rights. If an ambulance company bills you for services after Medicare denies payment, contact the SHIP in your state for help with an appeal to review the case. If you can show, for example, that transport in your neighbor’s car would have been unsafe or that the hospital a mile away couldn’t meet your needs, Medicare should pay.
Mike Klug, Medicare Consultant