Medicare Part B covers ambulance services to or from a hospital, critical access hospital (CAH), or 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 an ambulance transportation to or from a dialysis facility.
Medicare will 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 is able to give you the necessary care.
You can get emergency ambulance transportation whey you have had a sudden medical emergency and your health is in serious danger because you cannot be safely transported by other means, like wheelchair van, car, or taxi.
Types of emergency ambulance transportation:
- You are in shock, unconscious, or bleeding heavily.
- You need skilled medical treatment during transport
You may be able to get non-emergency ambulance transportation if it’s needed to obtain treatment or diagnose your health condition and the use of any other transportation method could endanger your health.
Medicare may cover limited, medically necessary, non-emergency transportation if you have a written order from you doctor stating that an ambulance is necessary due to your medical condition. The transport may be medically necessary to get you to a hospital or other health facility.
If you require non-emergency but medically necessary ambulance transportation three or more times in a 10 day period of at least once a week for three weeks or more, Lancaster EMS may use a prior approval process (Prior Authorization). Lancaster EMS will send a request for prior authorization to Medicare before your fourth trip in a 30-day period, so that you will know earlier if Medicare will pay for the services. Either you or Lancaster EMS may request prior authorization for these scheduled, non-emergency transports. Prior authorization is currently required in New Jersey, Pennsylvania and South Carolina.
What does Medicare pay?
If Medicare covers your ambulance trip, they will pay 80% of the Medicare-approved amount after you have met the yearly Part B deductible. Medicare’s payment may be different if you are transported by a Critical Acute Hospital 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 will receive 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 claims or view electronic MSNs. Your MSN will tell you why Medicare didn’t pay for your ambulance trip.
Examples of why Medicare will deny:
- You chose to go to a facility further than the closest one, your notice may say this: “Payment for transportation is allowed on to the closest facility that 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 home or family is not covered.”