If you have Medicare coverage, you can get coverage for ambulance transportation to or from the hospital. The coverage also includes skilled nursing facility (SNF) or critical access hospital (CAH). It’s important to remember that Medicare will help you pay for ambulance services but only if other modes of transportation could be harmful for your health. This doesn’t necessarily mean you automatically quality for air ambulance transport either. First, let’s take a look at the medical necessity of availing ambulance transport.
Medical Requirement for Availing Ambulance Transport Under Medicare
Medicare will pay for the cost of emergency ambulance transportation in case of sudden medical emergencies with your health being in serious danger, provided that other modes of transportation like cars and taxi could endanger your health. You can get coverage for ambulance transportation if:
- You’re unconscious
- You’re bleeding heavily
- You’re in shock
- You require skilled medical treatment throughout the transportation
Requirements to Qualify for Air Ambulance Transport Under Medicare
The above-mentioned examples don’t necessarily qualify you fir air ambulance transport that is covered by Medicare. To be eligible for medical transport by air, your condition must require immediate and fast transportation that cannot be done through ground transportation. Medicare will cover for your expenses only if your condition fulfills the following requirements:
- Ground transportation can’t easily reach your location
- Obstacles like heavy traffic, long distances, etc. could prevent you from getting the immediate care that you require if you’re traveling by ground ambulance
There may even be a few but special instances wherein Medicare will cover for the cost of ambulance transport even in non-emergency cases. This is provided in case you have a doctor’s letter stating that your medical condition requires transportation with an ambulance.
If you felt the medical situation warranted the air ambulance trip, yet Medicare refused to cover the charges, you don’t necessarily have to be disheartened. You can still check a few things and appeal Medicare to cover the air ambulance expenses.
Check Your Paperwork and Medicare Summary Notice (MSN)
Medicare gives you the reason for not covering air ambulance trip and there can be two primary reasons for it:
- The air ambulance company failed to appropriately document your need for air ambulance transport: In a situation like this, contact the doctor or social worker who was involved in mandating the air ambulance transport. Send this information to the organization that handles your medical bills on behalf of Medicare.
- The air ambulance company failed to file appropriate paperwork: You can always ask your air ambulance company to re-file your claim. If this does not yield results, you can then proceed to file an appeal.
If Medicare Still Refuses to Pay, File an Appeal
People who have Medicare have certain rights and one such right is filing an appeal against non-coverage of your air ambulance bills. Here’s a stepwise approach:
Look at MSN and find reason for not covering the air ambulance trip: Apart from the reason, the MSN will also let you know the time by which you need to file the appeal.
- Follow the instructions on MSN to file the appeal against non-coverage of air ambulance trip: It will also contain the address to which you need to send the appeal. You must accompany it with a letter stating why your air ambulance trip must be covered.
- Get in touch with the doctor who suggested air ambulance services: Attach this information to the MSN before sending it to the designated address.
- Keep a copy for yourself: You might need the copy of your appeal as a proof, so make a copy and keep it with you.
You can also get in touch with Medicare at 1-800-MEDICARE or visit www.medicare.gov/appeals.
We’ve already discussed several criteria which need to be satisfied for air ambulance services to be covered by Medicare. We also know that an air ambulance service is not covered when you have ground ambulance available. We’ve also discussed the fact that only medical air transportation to the nearest “appropriate” medical facility is covered by Medicare. Well, this is not entirely true. You stand to gain at least part coverage in the above two situations through the Special Coverage Rule. It helps:
- People who feel air ambulance services are absolutely warranted contrary to what medical professionals opine
- People who are comfortable admitting the patient to the facility of their choice only
Understanding Air Ambulance Services in the Context of Special Coverage Rule
It is important to note here that the coverage is not extended to places that are not acute care facilities. Places such as physician’s office, nursing facility or the patient’s home would be excluded.
You Prefer Air Ambulance over Ground Ambulance: Now let’s suppose that the medical experts feel that an air ambulance is not warranted and the ground ambulance would suffice. In such a case, Medicare would pay an amount that would have afforded you ground ambulance. The rest of the money would have to be born by you. This amount may be small and would only offer a negligible respite.
You Want the Medical Facility of Your Choice: On the other hand, the medical experts might feel that air ambulance services are warranted. Here, you would be required to transfer the patient to the nearest appropriate facility. However, if you decide to transport the patient utilizing air ambulance services to a facility of your choice, which is at a greater distance than the nearest one, the cost of extra distance to reach it (from the nearest facility) would have to be born by you.
Remember, the air ambulance service provider can ask you for documentation, which clearly indicates that air ambulance services are necessary. Failing to produce the document can mean that you have to pay for the services and then claim it from Medicare.
Understanding what constitutes an air ambulance according to Medicare is necessary. The fact ensures that you get into an aircraft that is equipped enough to take care of you or your loved ones. According to “Medicare Benefit Policy Manual,” the air ambulance needs to be equipped and designed such that it can be of use during emergency and nonemergency situations. It is also essential that a US air ambulance or worldwide air ambulance service complies with the State as well as local laws.
Air Ambulance Equipment Requirements According to Medicare
The medical flight must be equipped with linens, stretcher, medical supplies for an emergency, oxygen supplies and equipment, and other vital emergency lifesavers or life-sustenance equipment. It must also contain support equipment such as neck and back boards, inflatable arm and leg splints. The air ambulance must be complete with necessary signage that signifies it is a medical flight. Telecommunication equipment must be present in accordance with the State or local law. In other words, there should be one wireless telephone or two-way voice radio at the minimum.
Adequate Staffing of Air Ambulance According to Medicare
If a basic life support air ambulance is chosen, it must have two people at the minimum with at least one of them being a certified EMT or emergency medical technician. The certification must have been granted by the state or local authority. The person must have legal authorization to operate lifesaving equipment onboard the medical flight. Any advanced life support air ambulance too must be staffed with two people with at least one being an EMT paramedic or EMT intermediate.
Statement of Compliance to be Furnished by Air Ambulance Service Provider
A statement that signifies compliance to norms laid down by Medicare is necessary for reimbursements. Medicare might ask the air ambulance service provider to furnish these at its discretion, although the information might not be asked for with every flight. The documentary evidence must contain letters from State or local authorities such as certificates, permits and licenses to name a few. Although checking for compliance is not a beneficiary’s responsibility, keeping oneself informed always helps.