Finally! A Guide to Ambulance Transportation Benefits under Medicare

Does Medicare cover ambulance transportation? How about transport in a wheelchair van? Will Medicare cover my trip to East Orange General Hospital for an imaging test?

There’s a lot of confusion surrounding Medicare’s transportation benefits. We’ve put together this guide to help you understand your benefits and coverage of ambulance transports under Medicare Part B.

First of all, let’s talk about why you would need an ambulance transport in the first place. When you’re in a long-term care facility, your primary doctor comes to you. Your rehab comes to you. At Park Crescent, you can also get your wound care in-house. But if you need to see a specialist, get dialysis, or undergo a procedure at the hospital, you’ll need a way to get there. And if you’re wheelchair bound or bed confined, transportation isn’t so easy.

Park Crescent works with a top-notch ambulance service, Gem Ambulance, to handle our residents’ transportation needs. They provide transports in ambulances and wheelchair vans. Medicare covers transport via ambulance, called basic life support (BLS), with some conditions. Medicare does not cover transport in wheelchair vans, otherwise known as mobility access vehicles (MAV).

Here’s what you need to know about your coverage:

Which part of Medicare covers ambulance transportation?

As we’ve mentioned before, Medicare has two main parts. To recap quickly, Part A covers inpatient services while Part B covers outpatient services. Ambulance transports fall under outpatient services in Part B. Therefore, Medicare will cover ambulance services at 80 percent after you meet the $183 deductible for 2018. Your co-payment for ambulance services in New Jersey will be about $80, depending on the distance of the trip. Your Medigap policy will usually cover the balance.

Ambulance claims usually include two charges: the base charge and the mileage charge. Additional services and supplies, such as oxygen, are included in the base rate.

Does Medicare cover all ambulance transportation?

In short, no. Medicare only covers transports that are medically necessary and for a covered, medical purpose. Let’s unpack this a bit more:

Emergency Transports: Covered

Medicare covers all transports to the emergency room. Because it’s an emergency situation, Medicare will generally only cover mileage to the closest hospital. Even if your doctor recommends you go to a further hospital that offers better care, Medicare may decide not to cover the extra mileage. In that case, you will have to pay the extra mileage out of pocket. Of course, many times the extra charge is worth it for better care.

Non-emergency Transports: Depends

This is where it starts to get confusing. There are a few different types of non-emergency BLS transports, and there are subtle differences between them. Whether or not Medicare covers your transport depends on the kind of transport, pickup location, and drop off location. Here’s the basic rule:

Medicare covers non-emergency ambulance rides that are:

1. Medically necessary—you are bed-confined and can only travel by ambulance;
2. For a medical purpose—to get dialysis, radiation therapy, or any other medical service; and
3. To or from covered medical facilities—a hospital, skilled nursing facility, dialysis center, or certain clinics.

Medicare has strict guidelines to decide what constitutes the first criterion—medical necessity. Your doctor or nurse will make the determination that you need ambulance transportation, and they will  sign a Certificate of Medical Necessity (CMN) for each transport.

The second and third criteria for coverage are self-explanatory. Medicare will not cover ambulance transportation provided for personal reasons. So if you’re going to a family event, or you want to switch facilities to be closer to your loved ones, you will have to pay for the transport.

You may have noticed I didn’t include “doctor’s office” in the list of covered medical facilities above. That’s because Medicare doesn’t cover transportation to physicians’ offices, because your doctor is supposed to see you at the facility under Part A. If you are in your “Part A stay”—within the first 100 days of receiving rehab or other skilled nursing services—any transports to see a doctor are included in the bundled Part A payment to your SNF. In other words, your facility will cover your transport. Once you’re out of Part A, you become responsible for transports to a doctor’s office.

Frequent Transports: Depends

Some patients require regular transports by ambulance, called frequent or repetitive transports. This can be for chemotherapy or radiation at a hospital, dialysis treatment for kidney failure, or other services. Since ambulance transports are costly, Medicare now requires New Jersey repetitive transports to be approved in advance. Your doctor needs to complete a Certificate of Medical Necessity before the fourth transport, and it’s valid for 60 days. Your ambulance provider will then apply to Medicare for authorization of your frequent transports. Like the CMN rule, the authorization needs to be in place before the fourth transport, and it covers up to 80 ambulance rides in 60 days. The approval needs to be renewed every two months.

Here’s a handy chart I put together breaking up coverage and Medicare requirements:

If Medicare denies authorization of your frequency, don’t worry. Your doctor, facility, and ambulance provider will work together to try to reinstate your coverage or figure out other options for you. For example, even if you’re bed-confined, you may be able to tolerate a short ride in a wheelchair van with support.

Still Confused?

Everyone has a right to understand their coverage and what costs they’ll face with ambulance transportation. Since most SNF residents will probably need transport at some point during their stay, this information is important to know. If you have any questions about your ambulance transport, let us know in the comments, or check with your nurse.