The wail of sirens may be the lifeline your loved one needs to recovery and health in the event of a medical emergency or event. So today we will look at if and when your parent or loved one needs ambulance service or emergency transport, is it covered by Medicare and how?
First, we will assume that your loved one is covered by original Medicare, with the red, white and blue card. Original Medicare is a baseline of service, if your loved one has Medicare Advantage or another Medicare health plan the rules may be different, but they must offer at least the same amount of coverage as original Medicare.
Medicare Part B, Medical Insurance, is the portion of Medicare that covers ambulance service. There are criteria that must be met before Medicare will cover emergency transport:
The golden rule of Medicare and Ambulance transport is this:
Emergency ambulance service is covered to and from a hospital, critical access hospital or skilled nursing facility:
- ONLY when other transportation could impact or endanger your loved ones health
Severe pain, bleeding, shock, or unconsciousness are all examples of situation which emergency transport would be reasonable.
- Only to the nearest appropriate medical facility with the level of care you need
Emergency Air Transportation, such as helicopter, may be considered reasonable if your location is remote or cannot be reached easily or timely by ground transportation.
How about non-emergency ambulance transportation?
In the case of a non-emergency for diagnosis or treatment, Medicare may cover ambulance service, IF other transportation could impact or endanger your loved ones health.
It would be wise to consider getting a statement from your loved ones doctor if they feel that such an event may occur or be necessary. For more information on talking to your loved ones doctor, including a checklist and questions to ask, go check out our free Parenting Upward Guide.
What is an ABN and why am I or my loved one being asked to sign it?
An Advance Beneficiary Notice, or ABN, is a form that the ambulance company will present if they have doubts that Medicare will cover the cost of a questionable, or non-emergency transport. The ABN allows you or your loved on to choose to accept ambulance service and explains the financial responsibility. If you choose that you both want and will pay and you sign the ABN, you or your loved one is responsible for paying if Medicare declines to do so.
The ambulance company can refuse service if you do not sign, but they should NOT ask you to sign an ABN in a clear medical emergency situation.
What will I or my loved one be responsible to pay?
Remember that Ambulance service is covered under Medicare part B, which has a deductible. In 2013, this amount is 147.00.
Once your loved one has met that 147.00 deductible, then you will only be obligated to pay 20% of the Medicare-approved amount. Medicare will pay 80%.
How will I know if my loved one was covered?
Your next Medicare Summary Notice will advise you if Medicare did or did not pay for the transport. If Medicare did not cover it they will provide a statement why.
If you have questions about the Medicare payment you can call the number on the summary notice or 1-800-Medicare.
What if it was not covered but I believe it should be?
Two specific situations to look for are:
- The reason for the emergency/ambulance transportation was not documented fully.
In this case, contact the doctor or discharge nurse at the hospital to request documentation or their help in providing the appropriate documentation to Medicare. The Medicare Summary Notice will have an address to send these documents to.
- The claim was not filed or was filed improperly
If this is the case, ask the ambulance company to refile the claim. DO NOT pay anything until they have done this. If the claim is still not resolved you can file and appeal. The instructions to do this should also be on the Medicare Summary Notice.
More information can also be found in the official booklet on Medicare.gov.
Next time we will look at how to file an appeal with Medicare for an unpaid claim. Don’t miss it! Sign up for our e-mail newsletter today!