Topic:
MEDICAL PERSONNEL; MEDICARE; PARAMEDICAL PERSONNEL;
Location:
INSURANCE - HEALTH;

OLR Research Report


July 8, 1998 98-R-0862

FROM: Robin Cohen, Principal Analyst

RE: Medicare Coverage of Paramedic Services

You asked if (2) Medicare pays for paramedic services and (2) any state law stipulates the services for which Medicare can or cannot pay.

SUMMARY

Medicare Part B will pay for ambulance services, including those where an ambulance is intercepted by a paramedic for advanced life support services. The key is in the billing. Medicare will pay as long as the services are billed on a single form as one service.

Only federal law governs who qualifies for Medicare and what services are covered. Medicare encompasses both Part A (primarily hospitalization) and Part B (doctor's visits and other outpatient services). Part B (which covers ambulance services) requires individuals to pay premiums, deductibles, and coinsurance. (State regulations require the Department of Social Services (DSS) to pay these for certain people with low income and assets.)

State law specifies what services Medicare supplement policies must cover. It also establishes (1) a Medicare Assignment program which prohibits doctors who accept certain Medicare patients from balance billing (i.e., billing the patient for whatever Medicare payment does not cover), (2) penalties for Medicare vendors who defraud the state, (3) prohibitions against reductions in employer-sponsored health insurance due to Medicare eligibility, and (4) a requirement that nursing homes post signs indicating whether they participate in the Medicare program.

The Center for Medicare Advocacy handles appeals of coverage denials for Medicare beneficiaries. The Center's Sara Lemieux indicates that it has been successful in appealing paramedic coverage denials. They can be reached at 1-800-262-4414.

MEDICARE COVERAGE OF PARAMEDIC INTERCEPTS

Federal law requires Medicare Part B to cover ambulance services but does not address paramedic intercepts. But, according to a June 1996 federal Health Care Financing Administration (HCFA) memorandum, Medicare policy permits one ambulance company to contract with another to obtain part of the components necessary to render a complete basic life support (BLS) or advanced life support (ALS) service. This combined service is considered a single ambulance service and must be billed on a single claim form by the ambulance provider that transports the patient to the hospital. HCFA also allows an ALS supplier to enter into agreements with volunteer ambulance companies (who do not charge for BLS services) where the former acts as the billing agent for the company. So even if the ambulance company does not provide the ALS service it can still bill for it and Medicare will reimburse it at the ALS rate. Then it is up to the ambulance company to pay the ALS contractor. As with any other service Medicare covers, the paramedic service would have to be reasonable and necessary.

RC:pa