How does Medicare cover ambulance services? About three months ago, I took an ambulance to the hospital emergency room because I rarely drive anymore, and I just received a $1,100 bill from the ambulance company.
This is a Medicare issue that confuses many people. Yes, Medicare does cover emergency ambulance services. In limited cases, non-emergency ambulance services may be covered too, but only when they are deemed medically necessary and reasonable. What does that mean?
First, it means that your medical condition must be serious enough that you need an ambulance to transport you safely to a hospital or other facility where you receive care that Medicare covers. If a car or taxi could transport you without endangering your health, Medicare will not cover a ride in the ambulance. For example, it is likely Medicare will not pay for an ambulance to take someone with a simple arm fracture to a hospital. But if he or she goes into shock or is prone to internal bleeding, ambulance transport may be medically necessary to ensure the patient's safety. The details make a difference.
Second, the ambulance must take you to the nearest appropriate facility, meaning the closest hospital, critical access hospital, skilled nursing facility or dialysis facility generally equipped to provide the services your illness or injury requires. 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 nearest hospital does not have a burn unit.
Similarly, if you live in a rural area where the nearest hospital equipped to treat you is a two-hour drive away, Medicare may pay. But if you want an ambulance to take you to a more distant hospital because the doctor you prefer has staff privileges there, expect to pay a greater share of the bill. Medicare will only cover the cost of ambulance transport to the nearest appropriate facility and no more.
In limited cases, Medicare will also cover non-emergency ambulance services if such transportation is needed to treat or diagnose your health condition and the use of any other transportation method could endanger your health. Not having another means of transportation is not sufficient for Medicare to pay for services. Some examples include transportation to get dialysis or if you are staying in a skilled nursing facility and require medical care. In these cases, a doctor's order may be required to prove that use of an ambulance is medically necessary.
The cost for ambulance services can vary from several hundred to several thousand dollars depending on where you live and how far you are transported.
Under original Medicare, Part B pays 80% of the Medicare-approved amounts for ambulance rides. You, or your Medicare supplemental policy (if you have one), will need to pay the remaining 20%.
If you have a Medicare Advantage Plan, it must cover the same services as original Medicare, and may offer some additional transportation services. You will need to check with your plan for details.
How to Appeal
If an ambulance company bills you for services after Medicare denies payment, but you think the ride was medically necessary, you can appeal (see Medicare.gov/claims-appeals). Often, a lack of information about a person's condition or need for services can lead to denials.
If you need some help contact your State Health Insurance Assistance Program (SHIP). SHIP has counselors that can help you file an appeal for free. To locate your local SHIP, visit ShiptaCenter.org or call 877-839-2675.
For more information on this topic, call Medicare at 800-633-4227 and ask them to mail you a copy of the "Medicare Coverage of Ambulance Services" booklet, or you can see it online at Medicare.gov/Pubs/pdf/11021-Medicare-Coverage-of-Ambulance-Services.pdf.
Savvy Living is written by Jim Miller, a regular contributor to the NBC Today Show and author of "The Savvy Living" book. Any links in this article are offered as a service and there is no endorsement of any product. These articles are offered as a helpful and informative service to our friends and may not always reflect this organization's official position on some topics. Jim invites you to send your senior questions to: Savvy Living, P.O. Box 5443, Norman, OK 73070.