During the summer, Kira Milas worked as a swim instructor in southern California. One day as she swam in the pool, she accidentally knocked her head into a wall and broke several teeth. Not knowing the extent of the damages, an ambulance was called on her behalf. She was given a neck brace and taken to a local hospital 15 minutes away. The ambulance ride cost $1,772. Thankfully, insurance covered Milas’ bill, but many people aren’t so lucky. Does insurance cover ambulance services and rides? The answer is that it depends.
Out of pocket, the cost for an ambulance ride can be quite expensive. A Government Accountability Office report stated that the average cost for ambulance transportation in 2010 was $429. This included emergency and non-emergency rides, as well as Medicare and non-Medicare patients. The overall range was $224 to $2,204. The costs are rising too. Medicare publishes regular reports on ambulance costs, and in 2013 the annual expenses were over $6 billion. That is significantly higher than the $2 billion on ambulance services spent just 11 years earlier in 2002.
Ambulances are run by a wide variety of public and private ventures, including local hospitals, volunteer associations, fire departments, and other businesses. As a result, the services vary widely, as do the costs. When someone calls 911, the emergency dispatcher contacts an ambulance that is nearby to respond to the situation. They are more concerned with getting an ambulance there as quickly as possible rather than making sure that the ambulance company is covered under your health insurance. So, you likely won’t know whether the ambulance is in-network until you get the bill. In an emergency situation, you probably won’t care, or won’t be able to take the time to consider ambulance coverage either.
The purpose of using an ambulance is generally for emergency transportation to the nearest medical facility. In cases of accidents or unexpected life-threatening situations, a person can dial 911, speak with the operator, and request an ambulance. The ambulance will arrive as quickly as possible and speak with the patient, loved ones, or nearby witnesses to assess the situation. The injured or sick person may need treatment at the scene and/or en route to the hospital. In this case, the emergency medical technicians on board the ambulance will treat the person as best as possible, keeping them calm and in a stable condition.
While this is the main purpose of ambulance services, the vehicles are used in other ways as well. For example, imagine that you have experienced an accident while biking down a busy road and a witness called for an ambulance. You were wearing a helmet at the time of the accident, but still managed to hit the pavement pretty hard. You have a broken wrist, but are unsure whether or not you need to have your head examined. When the emergency team arrived, they assessed your current state and worked with you to determine whether or not you needed to go to the hospital. Though this is a non-emergency or life-threatening situation, you still choose to ride to the hospital in the ambulance in order to have a CT scan.
For non-emergency ambulance rides, the driver can take you to the hospital, rehabilitation center, specialized treatment center, between hospitals, or to a nursing facility. The amount of healthcare insurance coverage for non-emergency transport will depend upon your particular policy. It is important to fully understand the details of your coverage before choosing to ride in an ambulance when it is not medically necessary, as you may be paying for the entire ride out of pocket.
Ambulances are not limited to ground transportation. Airplane and helicopters are also available for emergency and non-emergency situations. However, air transport is generally used to quickly move patients from an accident scene to a hospital, or from one hospital to another. Certain hospitals specialize in specific services, like cardiology, trauma, or neurology, and a patient may be relocated in order to receive better care. As with other ambulance services, make sure you understand whether or not air transportation is covered by your insurance.
Types of Insurance
Every insurance plan is different, so it is best to speak with an independent insurance agent or healthcare representative in order to determine the ambulance services covered by your specific policy. If you are interested in expanding your ambulance coverage, they can help you select a different plan. The following list outlines the basic coverage found under each insurance option.
Medicare: Ambulance services are covered under Medicare Part B, which is part of the Original Medicare plan, along with Part A. The transportation can be to the hospital, between hospitals, or to a nursing home. There are some restrictions, however. Ambulance rides are only covered when it is medically necessary. This means that Part B only covers the ride when you are experiencing an emergency and need to get to the hospital as quickly as possible. In addition, the ride will only be covered if it is to the closest possible hospital. If you require specialized care, then the ambulance is permitted to take you to a different medical facility that can provide for you. However, if you request transportation to a hospital that is further away for other reasons, you will be charged an additional fee. You will also be charged in most non-emergency situations.
Air transportation is covered in certain circumstances. For example, if you experience an accident or health emergency and are in a location that is very remote, or difficult to access via ground transportation, then an ambulance helicopter or airplane will be sent to pick you up. You may also receive air transportation if the traffic is congested and would prevent you from getting to the hospital as quickly as possible.
If you have Original Medicare, then you will be expected to pay your Part B deductible as well as 20% of the total ambulance fee. The emergency transportation service will bill Medicare, and once they have agreed on the amount, you will be sent a bill for 20% of the charges. Remember that this is for an emergency situation in which an ambulance has brought you to the nearest hospital. Non-emergency and/or hospitals that are further away will cost you more.
Medicaid: Low-income individuals who qualify for Medicaid should speak with someone at their state health department to find out more about ambulance coverage through their insurance. Each state regulates the requirements for Medicaid eligibility as well as the particulars of the insurance policies available. This includes ambulance services. According to the Health and Human Services federal website, Medicaid does cover ambulance services for emergency situations. However, the ambulance that arrives on the scene must have a state license. For non-emergency situations, Medicaid will provide coverage if the patient’s doctor has composed a written statement explaining why an ambulance is necessary. You can find out more about your state’s Medicaid requirements and coverage here. For example, if you live in Alabama, ambulance services are covered for those who are labeled as “Categorically Needy”. There is no copayment and you only need prior approval if you are seeking air transportation.
Affordable Care Act Health Plans– There are a wide variety of healthcare plans available through the Affordable Care Act. Some are offered through the federal Health Insurance Marketplace, while some states have their own subsidized health care programs. Each will have some emergency transportation benefit, although there might be a deductible or copayment required. For example, on the Silver Plan, which is a middle-level plan through the Health Insurance Marketplace, there is a $250 copayment for the ambulance ride and $250 copayment for the emergency room visit.
Private Insurance– As with plans offered under the Affordable Care Act, private healthcare plans will vary in the ambulance benefits that they offer. It is best to speak with an insurance representative to learn more about the specifics of your insurance plan. You can expect a copayment between $15 and $100 for an ambulance service, or possibly a coinsurance payment for 10% to 50% of the fees. Like most other insurance plans, the insurer will likely not cover ambulance transportation for non-emergency situations, or if you request to be taken to a hospital that is father away. In addition, some ambulance companies will be in-network while others will not. Check with your insurer to find out more about their possible restrictions.
When a Claim is Denied
After using an ambulance, the ambulance company will send your insurance company a list of medical codes indicating the services they provided. The codes will tell the insurer whether or not the situation was an emergency or a non-emergency. They will then assess the rest of the services listed in order to determine how much to bill you.
If you find yourself in a situation where your ambulance claim has been denied and you are expected to pay a large bill out of pocket, there are still things you can do. First, call the ambulance company and ask about the codes they submitted. In some cases, the codes may have been mislabeled. They may have accidentally coded the service as non-emergency. If this happens, you can ask them to resubmit the corrected forms to your insurance provider. Then, call your insurer to let them know to expect new paperwork. This will prevent them from filing late fees against you for non-payment while waiting for the new bill to be created.
Speak with your independent healthcare insurance agent, or healthcare representative today. They will answer any questions you may have about your current ambulance coverage, ways to expand your coverage, and how to file appeals.
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