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Medicare Part B covers ambulance transportation to a health care facility when it’s medically necessary and transportation in any other vehicle would endanger your health. The tricky part is judging when these conditions are met, especially in an emergency when no health care professional is present to confirm an ambulance is the only appropriate method of transportation.
If you call 911, whether the responding ambulance or emergency medical services are public or private, Medicare will be billed for at least some ambulance services and you will pay some of the total cost, which can range from several hundred dollars to $1,000 or more. If you call for an ambulance and it isn't an emergency, Medicare will cover it only if specific conditions are met. So it’s important to understand key details of Medicare ambulance coverage.
Ambulance transportation for emergency care
If you believe a medical emergency exists and requires ambulance transportation to a treatment facility, call for one — and be sure someone follows up with providers to back up your claim.
"We see problems with claims when the question is whether there was an emergency," says Sarah Murdoch, director of client services at the Medicare Rights Center. "Make sure that the providers document the episode as an emergency. Make your case to them that it was reasonable to call for an ambulance given what you knew and what you were experiencing."
Ambulance services in nonemergency situations
Medicare will sometimes cover nonemergency ambulance transportation if a physician certifies that it’s medically necessary. The patient typically must be confined to bed or require vital medical services during the trip. The ambulance must take you to a facility that provides Medicare-covered service, whether it’s a hospital, skilled nursing facility or other health care setting.
In some situations, individuals have prearranged ambulance services multiple times per month. Medicare is rolling out a new model where prior authorization will be required before your fourth nonemergency round trip in a 30-day period, so the patient and the ambulance company will know whether the fourth transport will be authorized and paid by Medicare. If the patient doesn’t get an approval, they will be billed by the ambulance company.
Note that in a nonemergency situation, if a private ambulance company believes Medicare might deny a claim for a specific ambulance service, the company is required to give you an Advance Beneficiary Notice of Noncoverage, and you're responsible for the costs.
What you’ll pay for ambulance transportation
If you have only Original Medicare, you'll pay 20% of the Medicare-approved amount for ambulance services, and the Medicare Part B deductible, $226 in 2023, applies. Medicare covers ambulance transportation only to the nearest medical facility that can give you the required care.
If you have Medicare Supplement Insurance, or Medigap, your 20% share is generally covered by the plan.
However, if you request that the ambulance takes you to a location for treatment that isn’t the closest one, Part B and Medigap will pay only the cost to the closest location. In that case, you would have additional out-of-pocket costs to cover.
Medicare Advantage and ambulance coverage
Medicare Advantage must cover at least what Medicare Part B covers, but the costs will be different for ambulance services by plan. Often, there's a set copay for emergency ambulance services listed in your Medicare Advantage plan’s documents. In some parts of the country, plans may be available that provide additional coverage, but the details of coverage can be complex.
"You need to look deep into your plan’s Evidence of Coverage document to see if your particular situation will be covered," Murdoch says. This research can be worthwhile for chronically ill patients who are likely to require multiple ambulance trips for treatment, for example.
What to do if your ambulance claim is rejected
The first step is to review your Medicare Summary Notice, or MSN, to see why the claim was denied. Often, it’s a mistake or lack of information provided, so Medicare can’t determine if the ambulance cost is valid. Call the hospital, health center or physician who cared for you. Ask for complete information and resubmit the claim.
The ambulance service may not have filed the paperwork yet, or there may have been a mistake. Talk to them about fixing any errors and ask them to resubmit.
If your claim for ambulance services is still denied, consider filing an appeal. As the nonprofit Medicare Advocacy puts it: "Ambulance transportation is frequently inappropriately denied Medicare coverage. If a Medicare beneficiary’s transportation meets the coverage guidelines … but is denied Medicare coverage, appeal!"