Life After 50 Expo

Dear Jiha,

Can Medicare help with transportation even if there’s no medical emergency? I’m hoping to better understand Medicare’s coverage of ambulance rides.

-Jiha (Baltimore, MD)

Dear Jiha,

Medicare Part B covers emergency ambulance services and, in limited cases, non-emergency ambulance services. Medicare considers an emergency to be any situation when your health is in serious danger and you cannot be transported safely by other means. If your trip is scheduled when your health is not in immediate danger, it is not considered an emergency.

Part B covers emergency ambulance services if:

An ambulance is medically necessary, meaning it is the only safe way to transport you
The reason for your trip is to receive a Medicare-covered service or to return from receiving care
You are transported to and from certain locations, following Medicare’s coverage guidelines
And, the transportation supplier meets Medicare ambulance requirements

To be eligible for coverage of non-emergency ambulance services, you must:
Be confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair)
Or, need vital medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions

Medicare may cover unscheduled or irregular non-emergency trips, but if you live in a skilled nursing facility (SNF), a doctor’s written order may be required within 48 hours after the transport. Medicare may also cover scheduled, regular trips if the ambulance supplier receives a written order from your doctor ahead of time stating that transport is medically necessary.

Medicare never covers ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation. Medicare also does not cover ambulance transportation just because you lack access to alternative transportation.

Part B covers medically necessary emergency and non-emergency ambulance services at 80% of the Medicare-approved amount. In most cases, you pay a 20% coinsurance after you meet your Part B deductible ($226 in 2023). All ambulance companies that contract with Medicare must be participating providers. Note that if you are receiving SNF care under Part A, most ambulance transportation should be paid for by the SNF. The SNF should not bill Medicare for this service.

I hope this helps!

-Marci

The first day of summer is June 21. As UV intensity rises and we perhaps spend more time outdoors, it’s important to remember sun protection. The CDC recommends the following tips to protect your skin:

Stay in the shade when possible.
Wear clothing that covers your arms and legs.
Wear a hat with a wide brim to shade your face, head, ears, and neck.
Wear sunglasses to protect your eyes from eye diseases.
Use a sunscreen of SPF of 15 or higher.

Dear Marci,

I just learned about State Pharmaceutical Assistance Programs, or SPAPs. Can you tell me more about these programs and how they work?

-Jae (Durham, NC)

Dear Jae,

Many states offer State Pharmaceutical Assistance Programs (SPAPs) to help residents pay for prescription drugs. Each program works differently.

States may coordinate their drug assistance programs with Medicare’s prescription drug benefit, Part D. This means that some SPAPs require that you sign up for Part D in order to qualify for assistance.

Your SPAP may help pay for your Part D plan’s:

Premium
Deductible
Copayments
Costs during the coverage gap, if one applies

If a drug is covered by both your SPAP and your Part D plan, both the amount you pay for your prescriptions plus the amount the SPAP pays will count toward the out-of-pocket maximum you have to pay before reaching catastrophic coverage.

Some states have qualified SPAPs. Enrollment in a Qualified SPAP gives you a Special Enrollment Period (SEP) that allows you to enroll in or make changes to your Part D or Medicare Advantage coverage outside of the the usual enrollment periods.

Check this list of State Pharmaceutical Assistance Programs to find out if your state has an SPAP, whether you are eligible, how the SPAP works, and how to enroll. You can also call your State Health Insurance Assistance Program (SHIP) to learn more about SPAPs in your state.

-Marci

Many people serve as long-distance caregivers for friends and relatives who live far away. Long-distance caregivers can perform a variety of roles in the care of their friends and relatives, including by helping with finances or money management, arranging for in-home care, and providing emotional support for the primary caregiver. The National Institute on Aging suggests that if you are a long-distance caregiver, you should familiarize yourself with resources local to the person you are caring for. You can find these resources by visiting:

Eldercare Locator, 1-800-677-1116 (toll-free)
National Institute on Aging website
Family Care Navigator
Your state government’s website

Dear Marci,

I’m helping my father set up his treatment for substance use disorder. Does Medicare cover this kind of care?

-Saul (Arlington, VA)

Dear Saul,

Yes, Medicare should cover alcoholism and substance use disorder treatment for your father if:

His provider states that the services are medically necessary
He receives services from a Medicare-approved provider or facility
And, his provider sets up his plan of care
Medicare covers treatment in both inpatient and outpatient settings. Here are just a few examples of the services that Medicare covers:
Psychotherapy
Opioid treatment program (OTP) services
Patient education regarding diagnosis and treatment
Post-hospitalization follow-up
Part A should cover his care if he is hospitalized and needs substance use disorder treatment. If he is in an inpatient psychiatric hospital, keep in mind that Medicare only covers a total of 190 lifetime days. Once this limit has been reached, though, Medicare may cover care at a general hospital. A plan’s cost-sharing rules for an inpatient hospital stay should apply.

Part B should cover outpatient substance use disorder care he receives from a clinic, hospital outpatient department, or opioid treatment program. Original Medicare covers these services at 80% of the Medicare-approved amount. As long as he receives the service from a participating provider, he will pay a 20% coinsurance after meeting his Part B deductible. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to find participating providers. If he is enrolled in a Medicare Advantage Plan, contact his plan for information about costs, coverage, and in-network providers for substance use disorder treatment.

I hope this information is helpful to you and your father. Wishing him well on his recovery.

-Marci