You asked why (1) Medicaid does not pay for paramedic intercepts, (2) a Medicare beneficiary’s Plan J Medigap policy does not cover this, and (3) why some people ultimately refuse these services.

We believe your first question pertains to Medicare Part B, not Medicaid.

SUMMARY

Medicare Part B pays for many but not all medical services. In general, it pays for ambulance services (basic life support or BLS) but it does not always pay for the full cost when a separate paramedic ambulance meets the first ambulance and provides advance life support services (ALS) to the beneficiary. This is because federal Medicare law restricts the circumstances under which emergency response providers can bill Medicare for services.

Although someone may have a Medigap policy (in your constituent’s case a Plan J policy, one of the more extensive plans), this does not mean that that policy will pay for a service Medicare will not cover. Medigap policies typically cover the difference between the charge for the medical service and what Medicare pays. In fact, in most instances, if Medicare Part B will not pay for a particular service, a Medigap plan will likewise not cover it, according to Attorney Lara Staunin of the Center for Medicare Advocacy (CMA), a Connecticut-based Medicare advocacy organization.

A Medicare beneficiary who lives in a town that does not have a contract with a paramedic intercept company and who know the rules may refuse to take the paramedic service because she does not want to pay the bill.

CMA has apparently lobbied Congress to lift the restriction in federal law. As an alternative, town officials could be asked about setting up these contractual arrangements.

EMERGENCY AMBULANCES AND MEDICARE COVERAGE

When a Medicare beneficiary needs emergency care, she typically calls 911. If it is a serious emergency, the dispatcher will call both the town’s volunteer ambulance company and a paramedic from an emergency response company (this is also referred to as a paramedic intercept). But federal Medicare law allows the paramedic intercept to bill Medicare only when three conditions are met: (1) the intercept service is performed in a rural area (according to CMA’s Staunin, most of Connecticut is considered rural for this purpose), (2) the service is provided under contract with one or more volunteer ambulance services, and (3) the volunteer company must be prohibited by state law from billing anyone for any service it provides (42 CFR Part 410. 40).

Connecticut law contains no such bar. Therefore, the paramedic intercept company cannot bill Medicare directly. But, these companies can enter into billing contracts with the volunteer ambulance companies. In these instances, the volunteer company bills Medicare at a higher rate than it would normally (to incorporate the intercept costs). Once Medicare reimburses it, it pays the emergency response company for the paramedic costs.

The amount the intercept companies get is considerably less than what they would get if they billed the beneficiary directly, according to CMA, so many of them are disinclined to enter into these contractual arrangements. And some Medicare beneficiaries know when their towns do not have billing arrangements and will refuse paramedic intercept services to avoid paying the bill.

RC: dw