Medicare coverage of ambulance services

If you ever find yourself experiencing a medical emergency, you may need to call an ambulance. You may also need medical transport via ambulance between two different medical providers. But how do you know if Original Medicare or your Medicare Advantage plan will cover the charges?

Criteria for an emergency call

You can get emergency ambulance transportation when you’ve had a sudden medical emergency and your health is in serious danger because you can’t be safely transported by other means, like by car or taxi. Even if a car or taxi is not available to transport you, if you could have safely taken that mode of transportation, Medicare will not cover the ambulance services. The ambulance must also transport you to the nearest appropriate facility, usually a hospital. If you call an ambulance but are not transported, Medicare will not cover the cost of the ambulance call. If you are not transported to the nearest appropriate facility, Medicare will not cover the extra mileage to that facility. The nearest appropriate facility means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. For example, someone with end-stage renal disease may need to be transported to a hospital that has dialysis capabilities.

Criteria for facility-to-facility transport

You may be able to get emergency or non-emergency ambulance transportation from one medical facility to another if you need it to treat or diagnose your health condition and the use of any other transportation method could endanger your health. In some cases, Medicare may cover limited, medically necessary, non-emergency ambulance transportation if your doctor writes an order stating that ambulance transportation is necessary due to your medical condition. Even if a situation isn’t an emergency, ambulance transportation may be medically necessary to get you to a hospital or other covered health facility. For example, someone needing a specialized kind of surgery may need to be transported to the nearest facility that has the required specialist on staff. Again, if you are transported to a facility farther away, Medicare will not pay for that extra mileage.

*Note: if you have a Medicare Advantage plan, it must cover at least what Original Medicare covers, but it may provide additional coverage. For information about that coverage, see your plan’s evidence of coverage or contact your plan directly.

If you end up with ambulance services that have been denied, you have the option to appeal. For Original Medicare, you follow the appeal procedures outlined in your Medicare Summary Notice (MSN). For Medicare Advantage appeals, you will follow the appeal procedures outlined in your explanation of benefits (EOB). For assistance with these appeals, you may reach out to your local Elder Benefit Specialist (EBS). To find the EBS in your area, visit: https://www.dhs.wisconsin.gov/benefit-specialists/counties.htm.