Column: Medicare does not cover all ambulance services

Dear Savvy Senior: How does Medicare cover ambulance services? About three months ago I took an ambulance to the hospital emergency room because I rarely drive anymore, and I just received a $1,100 bill from the ambulance company. — Surprised Senior

Dear Surprised: This is a Medicare issue that confuses many seniors. Yes, Medicare does covers emergency ambulance services and, in limited cases, nonemergency ambulance services, too, but only when they’re deemed medically necessary and reasonable. So what does that mean?

First, it means that your medical condition must be serious enough that you need an ambulance to transport you safely to a hospital or other facility where you receive care that Medicare covers.

If a car or taxi could transport you without endangering your health, Medicare won’t pay. For example, Medicare probably won’t pay for an ambulance to take someone with a simple arm fracture to a hospital. But if he or she goes into shock or is prone to internal bleeding, ambulance transport may be medically necessary to ensure the patient’s safety on the way. The details make a difference.

Second, the ambulance must take you to the nearest appropriate facility, meaning the closest hospital, critical access hospital, skilled nursing facility or dialysis facility generally equipped to provide the services your illness or injury requires.

It also means the facility must have a physician or physician specialist available to treat your condition. Thus, Medicare might pay for an ambulance to take you to a more distant hospital if, for example, you are seriously burned and the nearest hospital doesn’t have a burn unit.

Similarly, if you live in a rural area where the nearest hospital equipped to treat you is a two-hour drive away, Medicare will pay. But if you want an ambulance to take you to a more distant hospital because the doctor you prefer has staff privileges there, expect to pay a greater share of the bill. Medicare will cover the cost of ambulance transport to the nearest appropriate facility and no more.

Nonemergency situations

In limited cases Medicare will also cover nonemergency ambulance services if such transportation is needed to treat or diagnose your health condition and the use of any other transportation method could endanger your health. Not having another means of transportation is not sufficient for Medicare to pay for services.

Some examples here are if you need transportation to get to dialysis or if you are staying in a skilled nursing facility and require medical care. In these cases a doctor’s order may be required to prove that use of an ambulance is medically necessary.

Ambulance costs

The cost for ambulance services can vary from several hundred to several thousand dollars depending on where you live and how far you’re transported.

Under original Medicare, Part B pays 80% of the Medicare-approved amounts for ambulance rides. You or your Medicare supplemental policy (if you have one) will need to pay the remaining 20%.

If you have a Medicare Advantage Plan, it must cover the same services as original Medicare, and might offer some additional transportation services. You’ll need to check with your plan for details.

How to appeal

If an ambulance company bills you for services after Medicare denies payment, but you think the ride was medically necessary, you can appeal (see Medicare.gov/claims-appeals). Often a lack of information about a person’s condition or need for services leads to denials.

If you need some help, contact your State Health Insurance Assistance Program, or SHIP, which has counselors who can help you file an appeal for free. To locate your local SHIP, visit ShiptaCenter.org or call 877-839-2675.

For more information on this topic, call Medicare at 800-633-4227 and ask to receive a copy of the “Medicare Coverage of Ambulance Services” booklet, or you can see it online at 808ne.ws/ambulance.

Jim Miller is a contributor to NBC-TV’s “Today” program and author of “The Savvy Senior.” Send your questions to Savvy Senior, P.O. Box 5443, Norman, OK 73070; or visit savvysenior.org.