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Emergency transportation is covered by Medicare Part B
Air transportation is only covered if the patient’s health condition necessitates it
Non-emergency transportation is only covered with a physician’s letter stating its necessity
If a patient demands which emergency facility they go to, the Medicare reimbursement may be different and the beneficiary must pay the difference in costs
Medicare may cover some transportation costs. If the transportation costs resulted from healthcare. The insurance company has strict guidelines about what transportation is covered and when.
To help you understand what services meet eligibility requirements, we’ve broken it down into sections below.
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Medicare Part B is medical insurance. If any transportation services are eligible for payment, it will only be available to Medicare Part B enrollees. Patients with Medicare Part A do not qualify for transportation benefits.
The kind of transportation Medicare will cover depends on the patient’s condition and location. In a medical emergency, ambulance transportation is covered if precise criteria guidelines are met. If a patient is experiencing a life-threatening emergency and air travel is needed, Medicare may cover the service.
In some situations, non-emergency ambulance transportation is eligible for payment. An example of non-emergency transport is a patient is who is non-ambulatory. It is harder to get non-emergency transportation covered than any other type of transportation.
A patient with Medicare Part B may have ambulance services covered if transportation is to or from a hospital. Patients in a skilled nursing facility (SNF), or critical access hospital (CAH) may also qualify for eligible services. Transportation is only covered by Medicare if transport by any other means would endanger a patient’s health.
Whether transportation is appropriate is the responsibility of Medicare claim reviewers. Analysts use information on the insurance claim to determine eligibility for transportation services. Examples of medical emergencies that would warrant emergency ambulance transportation include:
The list above is an example of typical conditions but is not exhaustive. Medicare ambulance transportation is only covered if a patient is taken to the nearest medical facility. To be eligible for payment, the facility must be able to provide the care the patient needs.
If a patient demands to choose a facility, Medicare’s reimbursement payment could be different.
If the chosen facility is not the nearest appropriate facility the payment schedule adjusts to what they would’ve paid for the closest facility. Most ambulance companies charge via distance, so the difference in charges could be large.
The beneficiary will be responsible for the difference. If there is no appropriate facility nearby, Medicare will pay for transportation charges to a non-local facility.
An alternative to ambulance transportation is transport by air. Medicare may pay for emergency transportation in a helicopter or airplane if a patient’s health condition requires such travel. Travel by air must be deemed faster than an ambulance to be considered.
It also must be established that any delay in care could result in loss of life or serious complications. Example scenarios that may qualify a patient for air travel rather than a traditional ambulance include:
In a few instances, Medicare Part B will cover non-emergency ambulance transportation. This type of transportation is covered if it is needed to diagnose a patient’s health condition. A doctor must determine that any other transportation could endanger the patient’s health.
For this type of travel to be covered, it must be a limited service and medically necessary. To be eligible for this kind of transport, a patient would need a written order from a physician.
The order would have to state why ambulance transportation is necessary, even though the patient is not having an emergency medical episode.
Doctors often order non-emergency ambulance transportation for patients with end-stage renal disease. End-stage patients are medically fragile and need rides to dialysis to survive. Transportation to and from a dialysis center may be dangerous with any other type of transportation. Non-emergency ambulance transport may be covered under Part B Medicare if a patient falls under certain criteria.
Under Medicare Part B, transportation is a covered service if it is medically necessary. What this means is an ambulance visit scheduled just for convenience from a patient’s home to a health care facility aren’t covered.
In this situation, a patient would be responsible for any outstanding balance after primary and secondary insurances pay.
If a patient receives an order from a physician for ambulance transportation, the service will only be covered if Medicare deems transport to be necessary.
Medicare has a set amount they will approve for patient transport. Transportation services that are part of Medicare’s network are required to accept the agreed amount. Patients with Medicare Part B will be responsible for 20% of the approved charge.
For example, if ambulance transportation took place due to a serious medical emergency, a company may charge $800. The company must accept the agreed amount from Medicare. Let’s say this approved amount is $400. When the patient receives their bill for the outstanding balance, it will be $80 rather than $160.
The difference in outstanding balance is because patients are only responsible for co-insurance based on the approved amount. The scenario above does not apply to anyone that falls under the situations listed below.
The outstanding balance may change for some patients. For example, if a Medicare patient has not met their yearly deductible, the patient would be responsible for any deductible amount not paid. This amount is in addition to 20 percent coinsurance.
The balance remaining after Medicare paid is eligible for secondary insurance or Medicare Advantage Plan payments. No ambulance company can bill a patient for any amount over 20 percent of the Medicare-approved amount.
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