Does Medicare Cover Ambulance Services?
This article was updated on: 10/21/2018
Emergency ambulance services and Medicare coverage
Medicare Part B (medical insurance) typically covers ambulance transportation when you’ve had a sudden medical emergency and your situation is such that:
- You need to get to a community hospital, critical access hospital, or skilled nursing facility for medically necessary care.
- Any other type of transportation (such as by car or taxi) would endanger your health.
How do you know if it’s a medical emergency? According to the Centers for Medicare & Medicaid Services (CMS), if someone is unconscious or in a state of shock, or experiences uncontrolled bleeding, it generally qualifies; these are just some examples of a medical emergency. As a general rule, emergency ambulance services are appropriate anytime your condition requires immediate skilled medical treatment during transportation.
In general, Medicare covers 80% of the Medicare-approved amount for the ambulance service, but your Part B deductible applies.
Emergency air transportation and Medicare coverage
While ground transportation is the more common emergency ambulance service, Medicare may also pay for emergency ambulance transportation in a helicopter or airplane. Emergency air transportation is appropriate if your health condition requires immediate transportation to medically necessary care and long distances, bad roads, heavy traffic or similar obstacles could prevent you from getting the medical care you need if you traveled by ground ambulance transportation.
Ambulance transportation to the nearest medical facility
In general, Medicare will only cover emergency ambulance services (ground or air) to the nearest medical facility that’s able to give you the care you need. If you choose to be transported to a facility farther away, Medicare’s coverage will be based on the charge to the closest facility that could provide the type of medical care you need. You would be responsible for paying in full for the extra miles between the nearest facility that could treat you and the facility of your choice. If no local facilities are able to give you the care you need, Medicare will typically cover transportation to the nearest facility outside your local area that’s able to give you the necessary care.
Non-emergency ambulance services and Medicare coverage
Medicare Part B typically doesn’t cover transportation to or from a doctor’s office. Under special circumstances, however, Medicare Part B may cover limited, medically necessary, non-emergency ambulance transportation from your home, a hospital, or a skilled nursing facility to a facility that provides the type of care you need to diagnose or treat your health condition.
There are several conditions that have to be met for Medicare to cover non-emergency ambulance services (all of the following must be true).
- You must have a written order from your doctor stating that ambulance transportation is medically necessary due to your medical condition.
- Travel by ambulance must be necessary to obtain treatment or diagnose your health condition.
- Travel by ambulance must be the only safe means of transportation available. (It is not sufficient that alternative transportation cannot be arranged. It is necessary to show that your health would have been jeopardized had you been transported any other way.)
If you are living with end-stage renal disease (also referred to as ESRD or permanent kidney failure requiring regular dialysis or a kidney transplant), Medicare Part B may cover round-trip transportation from your home or a skilled nursing facility to the closest facility that provides renal dialysis.
About repetitive non-emergency ambulance services
Do you need frequent ambulance transportation? You may want to learn about a “demonstration program” that Medicare is using in some states. This is a pilot program designed to improve factors like coverage and quality of care. This demonstration program is active in several states, including (but not necessarily limited to) New Jersey, Pennsylvania, South Carolina, Maryland, Delaware, the District of Columbia, North Carolina, Virginia, and West Virginia.
If you live in one of the states where the demonstration program is active and receive scheduled, non-emergency, medically necessary, round-trip ambulance transportation three or more times in a 10-day period, or at least once a week for three weeks or more, you may be notified about Medicare coverage of your services before non-emergency ambulance services are billed. Under this demonstration program, your ambulance company may request prior authorization from Medicare before your fourth round trip in a 30-day period. Either you or your ambulance company may request prior authorization for scheduled, non-emergency ambulance services. For more information, see Medicare.gov.
When Medicare doesn’t cover non-emergency ambulance services
In a non-emergency situation, if the ambulance provider believes that the transport may be denied coverage by Medicare, the provider must issue an Advance Beneficiary Notice (ABN) to notify you of your potential financial responsibility for the transport. If you agree to get the ambulance service and pay for it (by checking the option box and signing the ABN), you are responsible for paying for the service if Medicare doesn’t cover it. The ambulance provider may ask you to pay at the time of service. Therefore, it’s a good idea to ask whether the ambulance transportation will be covered before taking the trip in non-emergency situations.
Medicare Advantage coverage for ambulance services
If you have a Medicare Advantage plan, your plan must cover everything that’s included in Original Medicare Part A and Part B coverage. The exception is hospice care, which Part A covers directly instead of through the Medicare Advantage plan. Also known as Medicare Part C, the Medicare Advantage program lets private, Medicare-approved insurance companies offer Medicare health plans. Sometimes a Medicare Advantage plan may cover more than Original Medicare (Part A and Part B), with extra services or an expanded amount of coverage.
Some Medicare Advantage plans require you to use providers and hospitals within the plan network. For details about your plan’s coverage of ambulance services, refer to your plan’s Evidence of Coverage or contact the plan directly.
Under Medicare Advantage, you’re still in the Medicare program and need to pay your Part B premium. Copayments for Medicare Advantage plans may also be different than those for Part A or Part B. Other costs may also vary – for example, Medicare Advantage plans may have deductibles, premiums, and coinsurance charges. Each Medicare Advantage plan has an annual out-of-pocket maximum, so you’ll never spend more than that amount for covered Medicare services within a given year.
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This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.