If your loved one requires an ambulance for any reason, you might wonder whether or not Medicare will cover it. Ambulance transports are covered under Part B (outpatient) Medicare, but there are many regulations and limitations surrounding coverage.
It’s important to know your coverage and rights in advance. The best customer is an informed one, and that is especially true in medical care!
So here’s what you have to know about coverage of ambulance transports:
Before we go into the coverage of various types of transports, let’s talk about “allowed amounts” for a minute. Medicare has a capped amount they allow for each ambulance ride, and anything above that amount is the provider’s responsibility.
Medicare covers 80% of the allowed amount. You will be responsible for the 20% coinsurance, unless you have a Medigap plan and/or Medicaid. If you haven’t yet paid your deductible for the calendar year, you will need to pay it before coverage kicks in.
Medicare always covers transports for emergencies. When you call 911 during an emergency, the transport to the hospital will be covered at 80% of the allowed amount.
An emergency transport’s Medicare coinsurance is normally around $80. If you have Medicaid or a Medigap (Medicare supplement) plan, they will cover the balance. Many other secondary or supplemental insurance plans will cover the emergency transport coinsurance as well.
Non-emergency Ambulance Transports
Residents of nursing homes are able to see the attending doctor when he makes his rounds in the facility. But if they need to see a specialist—such as a cardiologist or dermatologist—they usually need to go to the doctor’s office. Nursing home residents also sometimes need to go to a hospital or clinic for certain treatments unavailable at their facility.
Usually, residents who need to go out for appointments are able to go by private car or taxi. But if your parent is bed-confined or otherwise unable to ride in a car, he or she will need a non-emergency ambulance transport. Medicare has strict rules about coverage for non-emergency transports.
The ambulance provider must get a doctor’s order affirming that an ambulance is necessary. They must also document the patient’s condition, and may not bill Medicare if the patient did not technically need the ambulance. Medicare automatically denies payment to any claim that does not meet their medical necessity standards.
Medicare also doesn’t cover transports to doctors’ offices. If your mom is at the facility under her Part A stay, the first 100 days of rehab care, the facility must pay for the transport. Otherwise, she will be responsible for the full cost of the transport.
Some secondary insurances will cover routine ambulance transports. If your mom or dad will need an ambulance for an appointment or treatment, check their coverage beforehand. This will help you avoid expensive surprises after the fact.
Repetitive Ambulance Transports
Say your dad is at Regency Heritage in Somerset, NJ, and has weekly wound care treatments at Robert Wood Johnson hospital. If he needs to go via ambulance—the wound location makes it difficult or impossible to sit, for example—Medicare considers that “repetitive transports”or a “frequency.”
Repetitive transports include trips to and from dialysis, chemotherapy, radiation, and wound care. The rules for repetitive transports are even stricter than those of regular one-time ambulance transports. Medicare only pays for trips that were authorized in advance and meet rigorous medical necessity standards. Frequencies that were not authorized or were found afterward to be medically unnecessary are the patient’s responsibility.
Medicare only covers ambulance transports to “covered” locations. These are typically a hospital, the patient’s residence, a skilled nursing facility, or a clinic. All other locations are not covered. If you want to bring your bed-confined parent to a family party, for example, be prepared to foot the bill.
Medicare will also only cover transfers from one facility to another if the second facility offers care unavailable at the first. If you want to switch mom or dad to a skilled nursing facility closer to you, Medicare will not cover that transport.
Mobility Access Vehicles (MAV)
Medicare doesn’t cover non-ambulance transports, even for medical reasons. Trips in private cars, taxis, paratransit services, or any other specialized vehicle will not be covered. Some private insurances will cover transports in certified wheelchair vans.
Be an Informed Customer
If your loved one needs to go by ambulance for a routine appointment, here are some questions you can ask to make sure you won’t be hit with unexpected charges:
- Does he or she absolutely require an ambulance?
- Why can’t I take him or her in my car?
- Did his or her doctor sign a Certificate of Medical Necessity?
- Were all required authorizations for both Medicare and private insurance obtained?
- If the transport is to a doctor’s office, will the facility cover the transport?
- What will my parent’s out-of-pocket cost be?
- Which company will be transporting my parent? How can I reach them with questions?
If your parent receives a bill you think is too high, or you feel Medicare should have paid for the trip, you have the right to appeal to Medicare. You can also contact the ambulance company and request an explanation for the charge.