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September 2002

Many people who are elderly or disabled and have Medicare insurance need to get to the doctor or the hospital. Sometimes they must make the trip by ambulance. This can cost a lot of money. Earlier this year, Medicare changed how it pays for such services. New rules should mean lower bills for ambulance use.

Two changes took effect April 1, 2002. First, Medicare now says ambulance providers must accept “Medicare assignment” for those who get Medicare benefits. This means they must accept what Medicare will pay as payment in full. They can only bill the Medicare beneficiary for the co-pay amount. Most of the time this is 20% of the Medicare-allowed charge. This puts a limit on how much ambulance companies can charge people who get Medicare over and above what Medicare pays.

The second change deals with how Medicare covers ambulance service in non-emergency situations. Now the program will pay for ambulance transport when it is required by the eligible person’s medical condition. The Medicare beneficiary does not have to be confined to bed.   He or she might just need to get home after discharge from a hospital, or need to get from a nursing home to a doctor’s office.  Now it will be easier for them to get Medicare coverage for ambulance service.

One thing has not changed. Medicare still uses the “medical necessity” standard for what it will cover. This includes ambulance service. The person’s doctor must say is it medically necessary. Also, Medicare puts a limit on how far the ambulance trip can be. It will only pay to take the person to the nearest facility or hospital which can provide the needed services.
If Medicare decides not to pay for ambulance service, the person will get a notice to that effect. A Medicare beneficiary who is denied Medicare payment can file an appeal. For details on how appeal a Medicare denial, contact your local Iowa Legal Aid office. Iowans who are 60 or older can contact the Legal Hotline for Older Iowans.

People who get Medicare may be sued in small claims court by ambulance companies to collect the part of the bill that Medicare has not paid. If you are sued for an ambulance bill and have questions about your legal rights or if you want to know if you have defenses to the claim, contact your local Legal Aid office.

Call 1-800-532-1275 to find out which Iowa Legal Aid office serves your county. Iowans 60 or older can call the Legal Hotline for Older Iowans for help at 1-800-992-8161.