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HomeMy WebLinkAboutMedicare Coverage of Ambulance Services 2024 07 24w L-aa l ca re; "Ve'rAuk Table of contents Medicare coverage of ambulance services .......... 5 Emergency ambulance transportation 5 Air transportation 6 Non -emergency ambulance transportation .............. 6 "Advance Beneficiary Notice of Noncoverage" (ABN) ...... 7 Voluntary ABN .. . . . .. . . . .. . . .. . . . .. . . 8 Paying for ambulance services ................. 9 What do I pay? .......................... 9 What does Medicare pay? ...................... 9 How do I know if Medicare didn't pay for my ambulance service? .... 9 Medicare rights & protections . . . . .. . . . .. . . .. . .11 What can I do if Medicare doesn't pay for an ambulance trip? ......11 What if Medicare still won't pay? ................. 12 4 The information in this booklet applies to all people with Original Medicare. If you have a Medicare Advantage Plan or other Medicare health plan, you have the same basic benefits, but the rules vary by plan. Your costs, rights, protections, and choices about where you can get your care may be different. For more information, read your plan materials or call your plan. "Medicare Coverage of Ambulance Services" isn't a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings. The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048. 5 Medicare coverage of ambulance services Medicare Part B (Medical Insurance) covers ambulance services to or from a hospital, critical access hospital (CAH), rural emergency hospital (REH), or a skilled nursing facility (SNF). Medicare covers and helps pay for ambulance services only when other transportation could endanger your health, like if you have a health condition that requires this type of transportation. In some cases, Medicare may also cover ambulance services if you have End -Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant), or you need dialysis and need ambulance transportation to or from a dialysis facility. Medicare will only cover ambulance services to the nearest appropriate medical facility that can give you the care you need. If you choose to be transported to a facility farther away, Medicare will only pay up to what it costs to take you to the closest facility that can give you the care you need. If no local facilities can to give you the care you need, Medicare will pay for transportation to the nearest facility outside your local area that can give you necessary care. Emergency ambulance transportation You can get emergency ambulance transportation when you've had a sudden medical emergency, your health is in serious danger, and you can't be safely transported by other means, like by car or taxi. Medicare might cover emergency ambulance transportation when: ■ You're in shock, unconscious, or bleeding heavily. ■ You need skilled medical treatment during transportation. Remember, these are only examples. Medicare coverage depends on the seriousness of your medical condition and if you could've been safely transported by other means. 6 AO e (" iii c i a iie c c') v u,e�n i n� u m j ue,�n (),illn� �u°u� wu I�° gyp �ii a III n������u iu ui c u �n a �n ii v iii ���, a �n ����u lilt tiliu iliu lull'o iii l Non -emergency ambulance transportation You may be able to get non -emergency ambulance transportation if you need it to treat or diagnose your health condition and the use of any other transportation method could endanger your health. In some cases, Medicare may cover limited, medically necessary, non -emergency ambulance transportation if your doctor writes an order stating that you need ambulance transportation due to your medical condition. Even if a situation isn't an emergency, ambulance transportation may be medically necessary to get you to a hospital or other covered health facility. Medicare prior authorization program If you get scheduled, non -emergency ambulance transportation for 3 or more round trips in a 10-day period or at least once a week for 3 weeks or more, you may be affected by a Medicare prior authorization program. Under this program, your ambulance company may send a request for prior authorization to Medicare, so you and the company will know earlier in the process if Medicare is likely to cover your services. The Medicare benefit isn't changing. Either you or your ambulance company may request prior authorization for these repeated, scheduled, non -emergency ambulance services. If your prior authorization request isn't approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges. For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Visit Medicare.gov/coverage/ambulance-services for the latest updates on the Medicare prior authorization program. 101 e (1J III c ifl e cove i ,a c; e flI aa III i ce o w &,, VII c e s 7 "Advance Beneficiary Notice of Noncoverage" (ABN) nipany )elieves LhaL Medicare niay TIO J)ay ai l• L11- J)a1-Li Lda1- ABNs have options that allow you to choose if you want the service and explain your responsibility to pay for the service If you choose the option showing that you want and will pay for the service, and you sign the ABN, you're responsible for paying if Medicare doesn't. The ambulance provider or supplier may ask you to pay at the time of service. Example: Mr. Smith is a hospital inpatient and needs to travel to a different hospital for a procedure that he can't get in the hospital where he was admitted. Mr. Smith requires ground ambulance transportation because of his medical conditions, but he asks for air ambulance transportation instead. Medicare will cover the cost of the ground ambulance transportation, but won't cover air ambulance transportation because this level of service isn't medically reasonable or necessary. The ambulance company must give Mr. Smith an ABN before transporting him by air ambulance, or the ambulance company will be responsible for any costs over the amount that Medicare would've paid for ground ambulance transportation. 8 III AO e (1, iii c z l i� e c c �) ��� �,e�n i� n� 1I ,�n(),illn� �°u� wu I�° gyp �ii i III n������� iu ui c � �n � �n ii v iii ���, � �n ����u Note: If you're in a situation that requires an ambulance company to give you an ABN and you refuse to sign it, the ambulance company will decide whether to take you by ambulance. If the ambulance company decides to take you and Medicare doesn't pay, you may still be responsible for the cost of the trip, even though you refused to sign the ABN. Voluntary ABN If an ambulance company believes that Medicare won't cover an ambulance service because it doesn't meet Medicare's definition of a covered service, it may give you a voluntary ABN as a courtesy. In this situation, the ambulance company isn't required to give you an ABN to bill you for the service. If the ambulance company gives you a voluntary ABN, you aren't required to choose an option or sign it. In this situation, the ambulance company expects that Medicare won't pay for the service, and you'll be financially responsible. Example: Mrs. Lee falls in her front yard and her neighbor calls an ambulance. She isn't in distress, but she can't stand up without having ankle pain. When the ambulance arrives, Mrs. Lee wants to go to the hospital, but she doesn't have a serious medical emergency and her health won't be in danger if she goes to the emergency room another way (like a car or taxi). Since Mrs. Lee could get to the hospital by another type of transportation without a serious risk to her health, Medicare won't cover the ambulance transportation. In this situation, the ambulance company isn't required to give Mrs. Lee any formal notice, but out of courtesy, they may give her an ABN, so that she knows she'll be billed for this service. If Medicare doesn't pay for your ambulance trip and you believe it should have, you may appeal. You must actually get the service and a claim for payment must be submitted to appeal Medicare's payment decision. Go to pages 11-12 for information. 0 Paying for ambulance services What do I pay? If Medicare covers your ambulance trip, you pay 20% of the Medicare -approved amount after you've met the yearly Part B deductible. In most cases, the ambulance company can't charge you more than 20% of the Medicare -approved amount and any unmet Part B deductible. All ambulance companies must accept the Medicare -approved amount as payment in full. Note: If a critical access hospital (CAH) or an entity owned and operated by a CAH transports you, what you and Medicare pay may be different. What does Medicare pay? If Medicare covers your ambulance trip, Medicare will pay 80% of the Medicare -approved amount after you've met the yearly Part B deductible. Medicare's payment may be different if you're transported by a CAH or an entity that's owned and operated by a CAH. How do I know if Medicare didn't pay for my ambulance service? You'll get a "Medicare Summary Notice" (MSN) in the mail every 3 months that lists all the services billed to Medicare, including ambulance services. Or, visit Medicare.gov to log into (or create) your secure Medicare account to check your Medicare claims or view monthly electronic MSNs. Your MSN will tell you why Medicare didn't pay for your ambulance trip. 10 �� �I:�:���un����� � lii iu�°ui °� �� .�����,,: � i��n n����� iir°u1'�)l 1 Ika iurii ce s ��e,�n i�,°Vces MSN examples for why Medicare didn't pay for your ambulance trip: ■ You chose to go to a facility farther than the closest one, so your notice says: "Payment for transportation is allowed only to the closest facility that can provide the necessary care." ■ You used an ambulance to move from one facility to another one closer to home, so your notice says: "Transportation to a facility to be closer to a home or family is not covered." Remember, these are only examples of statements you may find on your MSN. Statements vary depending on your situation. If you have questions about what Medicare paid, call the phone number on your MSN or 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 11 Medicare rights & protections What can I do if Medicare doesn't pay for an ambulance trip? If Medicare doesn't pay for an ambulance trip that you think should be covered, you or someone you trust can review your Medicare Summary Notice (MSN) and any other paperwork related to your ambulance bill. You may find errors that can be fixed. For example, while reviewing your MSN and other paperwork, you may find that Medicare denied your claim for one of these reasons: ■ The ambulance company didn't fully document why you needed ambulance transportation. If this happens, you can contact the doctor who treated you or the discharge social worker to get more information about your need for ambulance transportation. You can send this information to the company that handles bills for Medicare or ask your doctor to send it. Look on your MSN for the company's address. ■ The ambulance company didn't file the proper paperwork. If this happens, you can ask the ambulance company to refile your claim. If refiling your claim doesn't result in payment, you can file an appeal. 12 1011 e (1�fl i l� e I� III �.�� ��' What if Medicare still won't pay? If you have Medicare, you have certain guaranteed rights, including the right to appeal decisions about payment or coverage of services. If Medicare doesn't cover your ambulance trip, and you think your trip should've been covered, you have the right to appeal. An appeal is an action you take if you disagree with a coverage or payment decision Medicare makes. To file an appeal, follow these steps: 1. Review your "Medicare Summary Notice" (MSN). It will tell you why your bill wasn't paid, how long you have to file an appeal, and what steps you need to take. 2. Carefully follow the instructions on the MSN, sign it, and send it to the address of the company on the first page of the MSN. You may also include a letter explaining why you believe the ambulance trip should've been covered. 3. Ask your doctor or health care provider for any information that may help your case and attach copies to your signed MSN. 4. Keep a copy of everything you send to Medicare as part of your appeal. Or, you can use CMS Form 20027 and file it with the Medicare contractor at the address listed on the MSN. To view or print this form, visit CMS.gov/crosforms/downloads/cros20027.pdf, or call 1-800-MEDICARE (1-800-633-4227) to find out if a copy can be mailed to you. TTY users can call 1-877-486-2048. If you need more information or help filing an appeal: ■ Visit Medicare.gov/claims-appeals/how-do-i-file-an-appeal. Call your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org, or call 1-800-MEDICARE to get the phone number. 13 CMS fill IIIIIIII The Centers for Medicare & Medicaid Services (CMS) provides free auxiliary aids and services, including information in accessible formats like braille, large print, data or audio files, relay services and TTY communications. If you request information in an accessible format from CMS, you won't be disadvantaged by any additional time necessary to provide it. This means you'll get extra time to take any action if there's a delay in fulfilling your request. To request Medicare or Marketplace information in an accessible format you can: 1. Callus: For Medicare: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048. 2. Send us a fax: 1-844-530-3676. 3. Send us a letter: Centers for Medicare & Medicaid Services Offices of Hearings and Inquiries (OHI) 7500 Security Boulevard, Mail Stop DO-01-20 Baltimore, MD 21244-1850 Attn: Customer Accessibility Resource Staff (CARS) Your request should include your name, phone number, type of information you need (if known), and the mailing address where we should send the materials. We may contact you for additional information. Note: If you're enrolled in a Medicare Advantage Plan or Medicare Drug Plan, contact your plan to request its information in an accessible format. For Medicaid, contact your State or local Medicaid office. 14 The Centers for Medicare & Medicaid Services (CMS) doesn't exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex (including sexual orientation and gender identity), or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by CMS directly or through a contractor or any other entity with which CMS arranges to carry out its programs and activities. You can contact CMS in any of the ways included in this notice if you have any concerns about getting information in a format that you can use. You may also file a complaint if you think you've been subjected to discrimination in a CMS program or activity, including experiencing issues with getting information in an accessible format from any Medicare Advantage Plan, Medicare drug plan, state or local Medicaid office, or Marketplace Qualified Health Plans. There are three ways to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights: 1. Online: https://www.hhs.gov/civil-rights/filing-a-complaint/index.html. 2. By phone: Call 1-800-368-1019. TTY users can call 1-800-537-7697. 3. In writing: Send information about your complaint to: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 This product was produced at U.S. taxpayer expense. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Blvd. Baltimore, MD 21244-1850 Official Business Penalty for Private Use, $300 CMS Product No. 11021 Revised August 2023 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES This product is available in Spanish. To get a free copy, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Esta publicacion esta disponible en Espanol. Para obtener una copia gratis, flame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048.