Yes. Medicare will cover emergency and non-emergency ambulance services if:
- It is medically necessary, meaning that an ambulance is the only safe way to transport you and the reason for your trip is to receive a service or to return from a service that you need and Medicare will cover;
- You are transported to and from certain locations; and
- The supplier meets Medicare ambulance requirements.
An emergency is when your health is in serious danger and every second counts to prevent your health from getting worse.
If the trip is scheduled as a way to transport you from one location to another when your health is not in immediate danger, it is not considered an emergency. If it is not an emergency, Medicare coverage of ambulance services is very limited.
Medicare may cover non-emergency ambulance services if:
- You are confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair); or
- You need vital medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions.
Medicare may cover unscheduled or irregular non-emergency trips, but if you live in a skilled nursing facility (SNF), a doctor’s order may be required within 48 hours after the transport. If you are receiving SNF care under Part A, any ambulance transport should be paid for by the SNF. The SNF should not bill Medicare for this service.
Medicare may cover scheduled, regular trips if, the ambulance supplier gets your doctor’s written order ahead of time stating that ambulance transport is medically required.
Lack of access to alternative transportation alone will not justify Medicare coverage. Medicare will never pay for ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
If covered, Medicare will pay for 80% of its approved amount for the ambulance service. You or your supplemental insurance policy will be responsible for the remaining 20%. All ambulance providers must accept Medicare assignment, meaning they must accept the Medicare-approved amount as payment in full.
Note: If you live in New Jersey, Pennsylvania or South Carolina, you or the ambulance supplier must also request prior authorization from the Medicare Administrative Contractor (MAC) before providing repetitive, non-emergency ambulance trips. This is in addition to getting your doctor’s orders for ambulance services. The MAC should make a decision about the request and send you and the ambulance supplier a notice within 10 business days of the request. If the request gets approved, Medicare will often end up covering the claim after your ambulance trip. However, if the request is denied, the supplier can resubmit the paperwork to obtain prior authorization. If the problem cannot be corrected, there is only a small chance that Medicare will still end up paying for the claim if you receive non-emergency ambulance services. Contact your State Health Insurance Assistance Program (SHIP) for more information before you decide to use ambulance services if the authorization is denied. To find your SHIP’s contact information, visit www.shiptacenter.org and select your state.