Does Medicare cover ambulance service?
Medicare regulations specify that Medicare covers medically necessary ambulance transportation only. In other words, Medicare generally will not cover care by paramedics unless the paramedics transport you. Even if you are transported, Medicare will only cover your ambulance transportation if your ambulance transportation meets Medicare’s criteria for medical necessity.
Medical necessity criteria are set by Medicare, not TRAA.
What does Medicare consider “medically necessary” for ambulance coverage?
For Medicare to consider your ambulance transport to be medically necessary, it must meet the following criteria.
You must be transported to a hospital (physician's offices, dentist's offices, urgent care centers are not covered).
You must be transported to the closest hospital capable of caring for your condition.
Your condition must be of sufficient severity that going by some other means such as private car, taxi, or some method other than ambulance would be hazardous to your health. If you could go by some other means of transportation, Medicare will likely deny payment of your ambulance transport, even if the other means was not available at the time.
What is a “paramedic assist”?
A “paramedic assist” is when an advanced life support or ALS (Paramedic) ambulance meets with a basic life support (BLS) ambulance and the paramedics board the BLS ambulance service and the paramedics actually provide care for the patient. This is done in cases where the patient may need advanced care that cannot be provided by the BLS crew, or in cases where the patient’s condition is one that could deteriorate before reaching the hospital and may need paramedic care for potential life threatening conditions or advanced pain control.
There is no way to predict with 100% accuracy which conditions will deteriorate and which ones will not. TRAA and Allen County’s volunteer BLS ambulance services will always error on the side of patient care and all decisions are based on what the EMTs and paramedics feel is best for the patient.
Will Medicare pay for a “paramedic assist”?
The short answer is No.
Medicare pays for transportation, not care. If the patient is transported on the BLS ambulance, Medicare will pay the BLS ambulance for the “transport”, but will not pay the ALS (paramedic) unit for the care provided. This leaves the patient responsible for 100% of the ALS provider’s charges.
Residents of Allen County can protect themselves from this by joining TRAA’s LifeCare program. For more information on our LifeCare program, goto our LifeCare page.
How much will I owe if I have Medicare and use ambulance service?
Your out-of-pocket expense will vary depending on the following
1. If you have met your annual deductible if you have one.
2. If you have a Medicare supplemental insurance policy.
3. The level of care necessary for your condition.
4. Whether your ambulance transportation meets Medicare’s requirements for medically necessary or not.
5. Whether or not you are a LifeCare member.
If your transport meets Medicare’s requirements for medical necessity
1. Medicare will determine the “approved amount” for the level of service you required under Medicare’s guidelines.
2. You will owe any deductible you may have for the year plus 20% of Medicare’s approved amount.
3. If you have a Medicare supplement policy, it may pay the 20% co-payment for you. TRAA will bill your supplement for you as long as we have the correct information.
If your transport does not meet Medicare’s requirements for medical necessity:
You will be responsible for 100% of TRAA’s billed amount, not Medicare’s approved amount.
What if I am a LifeCare member?
Please see the LifeCare page on our website for complete LifeCare coverage information.
Want more information about Medicare coverage for ambulance service? Click here for more specific information from Medicare.