Ambulance Transports and Medicare: What Is and Isn’t Covered

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:

Allowed Amounts

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.

Emergency Transports

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.

Non-medical Transports

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.

A Guide To Medicare and Other Senior Health Benefit Programs

Medicare Maze!Joe Sanders never expected to wind up in the hospital for an extended stay. At age 68, he was in good health and leading an active life. So when a sudden heart attack on the golf course landed him in an emergency room, he was surprised to learn that his government health benefits weren’t going to see him through the long haul.

Unfortunately, like most of us, Joe never took a close look at his government entitlements and other options before an emergency struck. Had he fully understood his choices, he might have been better prepared to cope with the financial demands his care brought about. This article is designed to provide you with the basic information you’ll need to begin assessing your own health care coverage options.

Medicare Part A & B

Medicare is a two part program underwritten by the U.S Department of Health and Human Services that provides basic hospitalization and medical coverage for people age 65 and over. It also serves people under the age of 65 with certain disabilities. For example, if you have permanent kidney failure that is being treated with Dialysis or a transplant, or have been receiving Social Security or Railroad Retirement disability checks for at least 24 months, you are eligible for Medicare even if you’re under age 65.

Medicare Part A provides automatic hospital coverage, as long as you have worked at least 10 years in Medicare-covered employment. It also covers inpatient rehabilitation, sub-acute or skilled nursing care provided in a hospital or long term skilled nursing facility, as well as home health care and Hospice services. Part B helps cover medical and Doctors’ bills, and helps pay for rental or purchase of necessary medical equipment such as prostheses, wheelchairs and post surgical supplies. If you qualify for Medicare and have a non working spouse, he/she can also get Medicare parts A and B at age 65.

While part A is yours free of charge, Part B is considered elective coverage and requires monthly contributions. There are also several health care options available to Medicare beneficiaries, which come under the label of Medical Advantage. Most people receive a Medicare enrollment package just prior to their 65 birthday. At that point, they may choose whether or not to opt for Medicare Part B benefits and pay the required premiums for that coverage. If you have reached the age of 65 and have NOT received a Medicare Enrollment Package, you must call your local Social Security office in order to determine your eligibility.

The Medicare Part D: Prescription Drug Benefits

Introduced in January 2006, Medicare Part D is a prescription drug program available to all Medicare beneficiaries. Most people who qualify will pay reduced or no premiums and deductibles, and lower co-payments for their medication depending on their incomes and circumstances. Since private health insurance companies administer the program, monthly cost and coverage will also vary according to the company and plan you choose, as well as your state of residence. Premiums are in addition to the Part A and/or Part B premiums you may already be paying.

If you are currently taking prescription medication or thin you may in the future, you should explore your Part D options. Contact Social Security at 800-772-1213 or Centers for Medicare and Medicaid Services at 877-267-2323 or visit www.medicare.gov

Medicaid: Benefits for low income households

Medicaid is a combined federal-state program usually operated by state welfare or health departments and designed to furnish several basic services to low-income individuals. These include inpatient and outpatient hospital care, physicians’ services, nursing home care and laboratory and x-ray services. Under financial hardship, Medicaid may also be used to pay your Medicare premiums, deductibles and co-insurance.

MediGap: Benefits that take over where Medicare leaves off

MediGap refers to one of several supplemental health insurance policies that can be purchased to cover the costs Medicare often doesn’t cover, like prescription drugs, dental care, orthotics, hearing aids, or eyeglasses. For a complete list of recognized MediGap providers, contact the National Association of Sate Units on Aging, 1-202-898-2578 or visit www.nasua.org to locate the Office on Aging in your state.

Long-Term Care Insurance: Planning ahead for sudden continuing health care expenses.

Many people mistakenly believe that Medicare covers long-term care expenses such as nursing home and home health services. In fact, the program only pays short-term benefits for care in a skilled nursing facility and for part time skilled nursing visits at home. As for Medicaid, it does not generally pay for long-term care at home or for assisted living. As a result, if a person needs extended, non-nursing home health care, the only solution may rest with his or her ability to pay privately. That’s where long-term care insurance becomes a consideration.

Long-term care insurance is designed to pay for sudden, large, continuing healthcare expenses, whether care is provided in a nursing home, hospice, at home or elsewhere. Policies are sold through licensed insurance agents and brokers, and paid for from the policyholders’ private funds. It’s important to note that coverage is not limited to care for the elderly. As such, long-term care insurance may be a consideration for nearly every adult. As you would expect, premiums are significantly higher for older applicants who are at greater risk, therefore, the sooner you evaluate insurance options, the better.

Be An Educated Health Care Consumer: What you don’t know CAN hurt you.

Understand that most government entitlements are NOT automatic. You need to apply for them and meet all government requirements for coverage. Also, don’t assume that you’ll be covered for everything that comes along or you could be in for an expensive shock. Always familiarize yourself with the details of your medical coverage, and consider filling any gaps with an established supplementary plan. Consult an attorney or government counselor to help you make sense out of complex requirements or limitations in your coverage.