Medicare Part B Coverage
An ambulance service is deemed necessary for a patient who is either unconscious, heavily bleeding, or is unable to travel through any other mode of transport. Ambulance services are separately payable under Medicare Part B which pays 80 percent of the Medicare-approved cost. Ambulance providers cannot charge more than what is approved. Medicare ambulance benefit is confined to transportation and in the absence of transport, it is no payable service.
Ground Ambulance Coverage
Coverage under Medicare Part B for ambulance transportation is limited to only the situation wherein the patient is in dire need of medical care in a hospital or a skilled nursing facility, and when any other mode of transport would prove dangerous.
Medicare Part B does not cover transportation to and from a doctor’s clinic, however, under exceptional circumstances, in a non-emergency situation, with a doctor’s certification stating the necessity, Medicare Part B might pay.
Air Ambulance Coverage
An air ambulance is covered for transferring a patient from one hospital to another, provided the present hospital lacks inadequate facilities needed by the patient.
- The medically appropriate air ambulance is covered irrespective of region or state. However, claims are approved only if the beneficiary’s condition does not support the ground ambulance.
- Additionally, the air ambulance is also covered when it takes off for a pick-up but the beneficiary is pronounced dead prior to being boarded. This includes either before or after the ambulance arrives. However, this is only applicable if the ambulance service was otherwise deemed necessary.
- It is important to note that Medicare pays for transportation to only the closest facility that could provide care and in case of the absence of a facility in the locality; it will pay for the next closest facility outside the locality.
- Coverage requirements for ground and air ambulance transportation require the transport to be medically necessary, the patient to be a Medicare beneficiary, location to be local and facility to be an appropriate one.
- Medicare will also cover ambulance services if the patient is suffering from End-Stage Renal Disease, needs dialysis, and needs ambulance transportation to and from a dialysis facility.
- Finally, if the patient lives in New Jersey, South Carolina, or Pennsylvania, the ambulance supplier is bound to request prior authorization from the Medicare Administrative Contractor (MAC), before providing repetitive, non-emergency trips and this act is to be done excluding the physician’s order for ambulance services.