Medicare Insurance
What Does Medicare Cover?

Emergency Ambulance Transportation
In general, Medicare will cover medically necessary ambulance transportation to the nearest appropriate medical facility. Emergency ambulance transportation may qualify for Medicare coverage if the transport is a result of a sudden onset of a medical condition or traumatic injury manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, impairment to bodily function, or serious dysfunction to any bodily organ or part. Medicare requires that ambulance transportation be medically necessary and reasonable.

To be medically necessary, Medicare requires that the use of any other method of transportation would be hazardous to the patient’s health, whether or not any other methods of transportation are available. To be reasonable, for example, Medicare requires the patient to be transported to the nearest appropriate facility for treatment. Medicare will not pay for ambulance services when an ambulance was used for convenience of the patient, family, SNF staff or doctor, or because other means of transportation were not available at the time. The patient’s condition at the time of transport is the determining factor for a covered trip by Medicare/Medicaid.

Non-Emergency Ambulance Transportation

Certain medically necessary non-emergency ambulance transports are covered by Medicare, but wheelchair and gurney services are not covered benefits under the Medicare program.

Most non-emergency ambulance transports may require a certification of the medical necessity signed by the physician. Medicare will not pay for ambulance transportation to a particular hospital or facility that is not the nearest appropriate facility, or for the convenience of the patient, the family or physician.

In general, Medicare will not pay for non-emergency ambulance service unless the patient is unable to get out of bed without assistance, and unable to walk, and unable to sit in a chair or wheelchair, and/or that transportation by any other means would pose a hazard to the patient’s health. These items must be documented ahead of time in patient records by a physician. 

If you call 9-1-1 and we respond, but the patient appears not to meet medical necessity, or chooses not to be transported to the closest hospital facility, a patient will be asked to sign an “ABN” (Advance Beneficiary Notice) form before transporting. If the patients signs the ABN form making a choice and acknowledging they possibly do not meet Medicare requirements for transport by ambulance, and accepts responsibility for the entire bill, or any portion of the bill not paid for by Medicare we can transport to any hospital. If you refuse to sign the ABN, the ambulance company can decide whether or not to take you by ambulance. If the ambulance company decides to take you after you refuse to sign, you may still be responsible for paying the cost of the trip if Medicare doesn’t. However, if Medicare doesn’t pay for the ambulance trip and you believe it should have been covered, you may submit an appeal. You must get the service in order to appeal Medicare’s payment decision. Patients with medical necessity in emergency situations will not be asked to sign an ABN form.

Patient fees for Medicare, Medicaid, and Badgercare are determined by statute and Baldwin must accept their set fee as full assignment for emergency services provided. In the case of Medicare, the total allowed Medicare fee reflects both the 80% payment by Medicare and the 20% payment by the patient or the patient's supplemental insurance. If the transport and care is not medically necessary according to Medicare and they refuse to pay for the service, the patient must be billed the entire bill.

Important Points to Remember:

•If you choose to be transported to a specific facility, Medicare’s payment will be based on the payment rate to the closest appropriate facility. The patient must pay for the balance of the trip.

•If no local facilities are able to give you the care you need, Medicare will help pay for transportation to the nearest appropriate facility outside of your local area.

•Medicare won’t pay transportation from one facility to another so you can be closer to your home or family.

•If Medicare doesn’t cover your ambulance trip and you think it should have been covered, you have a right to appeal. Review your Medicare Summary Notice (MSN) to find out what appeal steps you can take.

•For non-emergency ambulance services, the ambulance company might ask you to sign an Advance Beneficiary Notice if they believe Medicare won’t pay for your trip. If you sign the notice, you are responsible for paying for the cost of the trip if Medicare doesn’t pay.

•If you are in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, what you pay and the rules for ambulance coverage maybe different. Read your plan materials or call your benefits administrator for more information.