Medicare Coverage of Ambulance Transportation

Posted by On Time Ambulance on 4/29/16 4:04 PM

The information below comes directly from Medicare Coverage of Ambulance Services, a free resource made available by Medicare.gov. Some emphasis has been added for clarity purposes.

Have questions about your specific Medicare transportation coverage situation in New Jersey? Contact us online or give us a call at

(908) 298 9500.


 

The following information applies to all people with Traditional Medicare.

If you have a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan, you have the same basic benefits, but the coverage can vary by plan.

Please note that Medicare does not cover wheelchair van or medical car services.

 

Medicare Coverage of Ambulance Services

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Medicare Part B (Medical Insurance) covers ambulance services to or from a hospital, critical access hospital (CAH), or a skilled nursing facility (SNF) only when other transportation could endanger your health. Medicare may also cover ambulance services if you have End-Stage Renal Disease (ESRD), need dialysis, and need ambulance transportation to or from a dialysis facility.

Medicare will only cover ambulance services to the nearest appropriate 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 payment will be based on the charge to the closest appropriate facility. If no local facilities are able to give you the care you need, Medicare will pay for transportation to the nearest facility outside your local area that’s able to give you necessary care.

 

Emergency Ambulance Transportation

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You can get emergency ambulance transportation when you’ve had a sudden medical emergency, and your health is in serious danger because you can’t be safely transported by other means, like by wheelchair van, car, or any lower mode of transportation. 

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.

Remember, these are only examples. Medicare coverage depends on the seriousness of your medical condition and whether you could’ve been safely transported by other means.

 

Non-Emergency Ambulance Transportation

You may be able to get non-emergency ambulance transportation if such transportation is needed to obtain treatment or 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 get you to a hospital or other health facility.

 

Prior Authorization

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If you get scheduled, non-emergency, medically necessary ambulance transportation 3 or more times in a 10-day period or at least once a week for 3 weeks or more from an ambulance company based in New Jersey, Pennsylvania, or South Carolina, you may be affected by a new 3-year demonstration program. Under this demonstration program, your ambulance company may use a prior approval process (called “prior authorization”) and send a request for prior authorization to Medicare before your fourth trip in a 30-day period, so you and the company will know earlier if Medicare will cover your services. Either you or your ambulance company may request prior authorization for these scheduled, non-emergency ambulance services.

 

 

“Advanced Beneficiary Notice of Noncoverage” (ABN) for non-emergency transportation

When you get ambulance services in a non-emergency situation, the ambulance company considers whether the transportation may be covered by Medicare. If the transportation would usually be covered, but the ambulance company believes that Medicare may not pay for your particular ambulance service because it isn’t medically reasonable and necessary, it must give you an “Advanced Beneficiary Notice of Noncoverage” (ABN) in order to charge you for the service. ABNs have option boxes that allow you to choose whether you want the service and explain your responsibility to pay for the service. If you choose the option box indicating that you want and will pay for the service, and you sign the ABN, you’re responsible for paying if Medicare doesn’t pay.

Example: Mr. Smith is a hospital inpatient and needs to travel to a different hospital for a special procedure that can’t be done in the hospital where he was admitted. Mr. Smith requires ground ambulance transportation because of his medical conditions, but he asks to be transported by air ambulance. Medicare will cover the cost of the ground ambulance transportation, but won’t cover air ambulance transportation because this level of service isn’t medically reasonable or necessary. The ambulance company must give Mr. Smith an ABN before transporting him by air ambulance or the ambulance company will be responsible for any costs over the amount that would’ve been paid for ground ambulance transportation.

If you’re in a situation that requires an ambulance company to give you an “Advanced Beneficiary Notice of Noncoverage” (ABN) and you refuse to sign it, the ambulance company will decide whether to take you by ambulance. If the ambulance company decides to take you, even though you refused to sign the ABN, you may still be responsible for paying the cost of the trip if Medicare doesn’t pay. You won’t be asked to sign an ABN in an emergency situation.

 

Voluntary ABN

If an ambulance company believes that Medicare won’t cover an ambulance service because it doesn’t meet Medicare’s definition of a covered service, it may give you a voluntary ABN as a courtesy. In this situation, the ambulance company isn’t required to give you an ABN in order to bill you for the service. If the ambulance company does give you a voluntary ABN, you aren’t required to choose an option box or sign it. In this situation, the ambulance company expects that Medicare won’t pay for the service, and you’ll be financially responsible if Medicare doesn’t pay.

Example: Mrs. Lee falls in her front yard and her neighbor calls an ambulance. She isn’t in distress, but she can’t stand up without having ankle pain. When the ambulance arrives, Mrs. Lee wants to go to the hospital, but she doesn’t have a serious medical emergency and her health won’t be in danger if she goes to the emergency room by another type of transportation (like a car or taxi). Since Mrs. Lee could get to the hospital by another type of transportation without a serious risk to her health, Medicare won’t cover the ambulance transportation. In this situation, the ambulance company isn’t required to give Mrs. Lee any formal notice, but out of courtesy, they may give her an ABN, so that she knows she’ll be billed for this service.

 

Paying for Ambulance Services

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What does Medicare pay?

If Medicare covers your ambulance trip, Medicare will pay 80% of the Medicare-approved amount after you’ve met the yearly Part B deductible. Medicare’s payment may be different if you’re transported by a CAH or an entity that’s owned and operated by a CAH.

How do I know if Medicare didn’t pay for my ambulance service?

You’ll get a “Medicare Summary Notice” (MSN) in the mail every 3 months that lists all the services billed to Medicare. You can also visit MyMedicare.gov to look at your Medicare claims or view electronic MSNs. Your MSN will tell you why Medicare didn’t pay for your ambulance trip.

Examples:

  • If you chose to go to a facility further than the closest one, your notice may say this: “Payment for transportation is allowed only to the closest facility than can provide the necessary care.”
  • If you used an ambulance to move from one facility to another one closer to home, your notice may say this: “Transportation to a facility to be closer to a home or family is not covered.”

 

Remember, these are only examples of statements you may see on your “Medicare Summary Notice” (MSN). Statements vary depending on your situation. If you have questions about what Medicare paid, call the phone number on your MSN or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Tags: Medicare, Medicare Prior Authorization, Non Emergency Medical Transportation

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