For emergency situations, whether for accident/injury or serious illness, emergency medical services may be needed for hospital transport.  A medical emergency occurs when a prudent layperson, with an average knowledge of health and medicine, believes that medical symptoms require immediate medical attention to prevent devastating illness, loss of life, loss of a limb, or loss of function of a limb.  The medical symptoms may be significant illness, injury, severe pain (including any unexplained or uncontrolled chest pain), or a medical condition that is rapidly getting worse.

Covered ambulance services include fixed-wing (airplane), rotary-wing (helicopter), and ground (truck) ambulance services, to the nearest appropriate facility that can provide care.  Emergency care is covered services that are rendered by a provider qualified to furnish emergency services and are needed to evaluate, treat, and/or stabilize an emergency medical condition.

Ambulance services are covered for those whose medical condition is such that other means of transportation could endanger the person’s health or is otherwise authorized by the plan.  This is known as non-emergency medical transport (NEMT) and is only appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by ambulance is medically required.

*Note that emergency medical services do not transport anywhere other than hospitals and, in some cases, freestanding emergency departments.

Also note that family is generally not permitted to accompany loved ones in an ambulance unless the transport is a minor (aged 17 or younger).