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Medicare and Medicaid Ambulance Coverage

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According to the Census Bureau statistics, there were approximately 47.5 million Americans enrolled in the Medicare Program alone in 2010.  This is an increase of over 13 million from 1990.[1] In addition to the Medicare Program enrollment statistics, the Kaiser Foundation reported approximately 50.4 million people were enrolled in a Medicaid type program at some point during 2010.[2] A quick snapshot of the Census Bureau statistical break down regarding Health Insurance coverage in the United States for 2011 based on 84.3% of the population reporting[3]:

 

  • Employment Based Health Insurance-55.1%
  • Direct Purchase of Health Insurance-9.8%
  • Medicare-15.2%
  • Medicaid16.5%
  • Military Health Care-4.4%
  • Uninsured-15.7%

 

With the number of Medicare recipients expected to continue to increase, understanding how Medicare reimburses is crucial to the sustainability of any Ambulance service provider.  This information is also vitally important to those individuals who are Medicare recipients.

 

Medicare Part B Coverage Overview[4]

Ambulance coverage only if it is deemed a danger to the health of the patient to travel by other methods.  The coverage is based on the facility that is closest and able to give the necessary care.  This includes to and from the following facilities.

  • Hospital
  • Critical Access Hospital
  • Skilled Nursing Facility
  • Other possible scenarios that Medicare Part B may cover ambulance transportation include:
    • Medical transportation is required from home to a medical facility for treatment due to a health condition; and/or
    • End-Stage Renal Disease, need dialysis, and other modes of transport could be detrimental to their health, thus requiring medical transport.

 

Medicare and Air Transportation*

Transport by helicopter or an airplane may be covered in cases that require immediate and quick response that a ground ambulance is unable to supply:

  • Ground ambulance is unable to reach the location in a timely and efficient manner
  • Traffic, distance, or other obstacles could prevent the patient from receiving timely care.

 

Medicare and Payment for Ambulance Services*

  • If approved-after the annual Part-B deductible has been met, Medicare will pay for 80% of the approved charges (payment by Medicare may differ if transported by a Critical Access Hospital vehicle)
  • Ambulance companies must accept the Medicare-approved fee amount as payment in full
  • Ambulance companies must provide a patient with an Advance Beneficiary Notice (ABN) if the service provider believes that Medicare may not pay for the transport.  In this case, if the patient signs the ABN, they will be responsible for payment if Medicare denies it.

 

Medicare Denies Payment*

If Medicare denies the payment to the Ambulance Company, the company that handles bills for Medicare will send the patient a Medicare Summary of Notice.  This notice will explain why the payment was denied.  At that point, the patient can either appeal the denial or choose to make payment arrangements with the medical transportation company.

 


[1] http://www.census.gov/compendia/statab/2012/tables/12s0146.pdf

[2] http://www.kff.org/medicaid/upload/8050-05.pdf

[3] http://www.census.gov/hhes/www/hlthins/data/historical/HIB_tables.html

[4] http://www.medicare.gov/Publications/pubs/pdf/11021.pdf

* refers to (4) footnote citation

* refers to (4) footnote citation

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