Conv-Ambulance Services, Medicare Reimbursement

How Medicare Covers Ambulance Services (Savvy Living)

December 2018 and September 2019

From: Steve Wiltsie

Date: December 27, 2018

Subject: It Was a Surprise to Me!

I’ve learned many things from this e-mail group, especially things about the VA medical benefits. If it wasn’t for this group, I wouldn’t have known that I was eligible for VA medical care since I had been in-country in Vietnam and had been assumed to have been exposed to Agent Orange. As it turns out, I ended up with hardening of the arteries in my heart because of that exposure and it caused a heart attack in mid-2017. I am considered 30% disabled by the VA and receive a monthly check due to that.

However, the reason I’m writing this note is to let you know something I found out recently the hard way. If you have a medical problem and someone calls an ambulance for you, be sure to let them transport you to the ER. If you do, and the problem is determined to be service-related, the VA will likely pay for the ambulance and the ER visit. If it is not service related, Medicare part B will likely pay up to 80% for the ambulance and the ER visit and, if you have a Medicare advantage policy, it may pay all or part of the rest. The main thing to realize is if you are NOT transported to the ER, NONE of this will be paid by the VA or Medicare and you will need to pay for the ambulance call yourself.
This happened to me recently when I was at an event at the local National Guard Armory. I began feeling dizzy and passed out before getting to a chair. Someone who knew I had a heart attack a year and a half ago called 911. I was checked out by the paramedics and began to feel much better. I decided not to be taken to the ER. In the end, my cardiologist had me take my blood pressure medication at night instead of in the morning and has taken me off of the blood thinner. The problem has gone away. The $2500 bill for the ambulance service arrived a few days later. I have checked with the VA and the insurance company and it is my responsibility to pay.
I hope this info can help anyone who didn’t know about this (then again, maybe I’m the only one who didn’t know it).

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From: Randy Kafka

Date: August 3, 2019

Subject: How Medicare Covers Ambulance Services

Savvy Living

How Medicare Covers Ambulance Services

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.

Non-Emergency Situations

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.

Ambulance Costs

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.