Medicare Supplement Insurance (Medigap) generally covers the out-of-pocket expenses for ambulance services approved by Original Medicare. These standardized policies, offered by private insurance companies, work with Medicare Parts A and B to cover costs like coinsurance and deductibles. Medigap acts as a secondary payer, filling the financial gaps after Original Medicare processes a claim. For ambulance transport, this supplemental coverage reduces or eliminates the patient’s financial responsibility for approved services.
Understanding Original Medicare’s Role in Ambulance Coverage
Original Medicare Part B provides the baseline coverage for ambulance services; Medigap coverage only applies after Medicare approves the claim. Ground ambulance transport must be deemed medically necessary, meaning using any other transportation method would endanger the patient’s health. This necessity is typically met in emergencies, such as sudden illness or injury where the patient is in shock, unconscious, or bleeding heavily.
Medicare Part B covers 80% of the approved amount for medically necessary ground ambulance services after the annual Part B deductible is met. The remaining 20% coinsurance is the financial gap that a Medigap policy is designed to cover. Medicare limits coverage to transport to the nearest appropriate medical facility capable of providing the required care.
If a patient chooses a facility further away, Medicare only covers the cost equivalent to transport to the closest appropriate hospital. The patient is responsible for additional mileage charges beyond that nearest facility. For non-emergency trips, a physician must provide a written order stating that ambulance transportation is required due to the patient’s medical condition.
How Medicare Supplement Plans Cover Remaining Costs
Medigap policies pay the remaining patient share only after Medicare Part B has approved and paid its 80% portion of the ambulance bill. The majority of standardized Medigap plans cover the 20% Part B coinsurance for ambulance services. This coverage is automatic once Medicare determines the service was medically necessary.
Plans F and G are the most comprehensive options and cover the entire 20% Part B coinsurance. Plan F is unavailable to people eligible for Medicare on or after January 1, 2020. Plan G offers the same comprehensive coinsurance coverage but requires the beneficiary to pay the Part B deductible.
Plan N also covers the Part B coinsurance at 100%. However, Plan N requires a copayment of up to $50 for emergency room visits that do not result in an inpatient admission. If the ambulance transport leads to hospital admission, the Plan N copayment does not apply, and the coinsurance is fully covered.
High-Deductible Options
Both Plans F and G offer a high-deductible option, requiring the beneficiary to pay all Medicare-covered costs up to a set annual deductible before the Medigap plan pays. Ambulance service costs count toward this high deductible amount. Once the deductible is met, the plan pays 100% of the remaining approved costs for the rest of the calendar year.
When Coverage is Limited or Denied
Medigap policies only pay for services that Original Medicare has approved; if Medicare denies a claim, the Medigap plan will also deny payment. The most common reason for denial is lack of medical necessity for the transport. If a patient could have been safely transported by a less costly means, such as a taxi or wheelchair van, Medicare will likely deny the claim.
For non-emergency transport, such as scheduled trips for dialysis, requirements are strict, often mandating that the patient be “bed confined.” Bed confinement means the patient is unable to get up from bed without assistance, walk, or sit in a chair or wheelchair. Routine transfers from a hospital to a nursing home without documented medical necessity are frequently denied.
Air Ambulance Limitations
Air ambulance transport, including helicopter and airplane, has strict limitations. Medicare only covers air transport in critical circumstances where ground transport is medically impossible or unsafe due to distance, weather, or heavy traffic. If a ground ambulance could have safely transported the patient in a timely manner, air ambulance coverage may be denied.
In non-emergency situations where coverage is uncertain, the ambulance company must issue an Advance Beneficiary Notice of Noncoverage (ABN). By signing this notice, the patient acknowledges potential financial responsibility if Medicare denies the claim. This ensures the patient is aware of the potential out-of-pocket cost before the service is rendered.
State Regulations and Choosing the Right Medigap Policy
Medigap plans are standardized across most of the country, but three states—Massachusetts, Minnesota, and Wisconsin—have their own non-standardized policies. Residents in these states must review specific policy guidelines, as plans use different names or structures than the standard lettered options.
When selecting a Medigap policy, individuals should review the Summary of Benefits to understand Part B coinsurance coverage. Plans F, G, and N provide the most comprehensive coverage for the 20% coinsurance and are popular options for predictable costs. Choosing a plan involves balancing the monthly premium cost against the desire for minimal out-of-pocket expenses.
Foreign Travel Emergency Coverage
Many Medigap plans include foreign travel emergency coverage, which can cover emergency ambulance services received outside the United States. This benefit is included in the following plans:
- Plan C
- Plan D
- Plan F
- Plan G
- Plan M
- Plan N
Coverage generally pays 80% of approved costs after a deductible, up to a lifetime limit of $50,000.