by Amy Natt, MS, CMC, CSA
Q: My wife lives in a care facility and was taken by ambulance to the local hospital. I was told that Medicare may not cover the cost. Can you please explain how this works?
A: Ambulance service is typically an expense covered, or partially covered, by health insurance when the ambulance is deemed medically necessary. There are several rules surrounding Medicare reimbursement for ambulance use, so this is a great opportunity to highlight some of those. If you are not yet Medicare eligible, call your health insurance provider to find out exactly what your plan covers. If you are Medicare eligible, make sure your supplemental policy has coverage for the 20 percent co-pay you may be billed.
According to www.MedicareInteractive.org, Medicare will cover emergency and non-emergency ambulance services, if:
It is medically necessary, meaning that an ambulance is the only safe way to transport you, and the reason for your trip is to receive a service or to return from a service that you need and Medicare will cover;
You are transported to and from certain locations; and
The supplier meets Medicare ambulance requirements.
An emergency is when your health is in serious danger and every second counts to prevent your health from getting worse.
If the trip is scheduled as a way to transport you from one location to another when your health is not in immediate danger, it is not considered an emergency. In a non-emergency situation, Medicare coverage of ambulance services is very limited.
Medicare.gov offers additional information that may help you understand some of the specifics.
How Often Is It Covered?
Medicare Part B covers ambulance services to or from a hospital, critical access hospital or skilled nursing facility. Medicare covers and helps pay for ambulance services only when other transportation could endanger your health, like if you have a health condition that requires this type of transportation.
Medicare only covers ambulance services to the nearest appropriate medical facility that’s able to provide the care you need. If you choose to be transported to a facility farther away, Medicare’s payment will be based on the charge to the closest appropriate facility. If no local facilities are available, Medicare will pay for transportation to the nearest facility outside your local area.
Emergency Ambulance Transportation
You may receive emergency ambulance transportation during a medical emergency in which your health is in serious danger, and you can’t be safely transported by other means.
These are some examples of when Medicare might cover emergency ambulance transportation:
You’re in shock, unconscious or bleeding heavily.
You need skilled medical treatment during transportation.
Non-emergency Ambulance Transportation
You may be able to obtain non-emergency ambulance transportation, if such transportation is needed to diagnose your health condition and the use of any other transportation method could endanger your health.
In some cases, Medicare may cover limited, medically necessary, non-emergency ambulance transportation, if you have a written order from your doctor stating that ambulance transportation is necessary due to your medical condition. Even though a situation isn’t an emergency, ambulance transportation may be medically necessary to transport you to a hospital or other health facility.
When you receive ambulance services in a non-emergency situation, and the ambulance company believes that Medicare may not pay for your particular ambulance service, it must give you an “Advance Beneficiary Notice of Noncoverage.”
If you receive scheduled, non-emergency ambulance transportation for three or more round trips in a 10-day period or at least once a week for three weeks or more from an ambulance company based in North Carolina and other specific states, you may now be affected by a Medicare demonstration program. Under this demonstration, your ambulance company may send a request for prior authorization to Medicare before your fourth round trip in a 30-day period, so you and the company will know earlier in the process if Medicare is likely to cover your services.
For more information on your specific situation, call 1-800-MEDICARE.
Readers may send questions to Natt, an Aging Life Care ProfessionalTM, certified senior advisor and CEO of Aging Outreach Services. She can be reached at firstname.lastname@example.org