| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Alaska
|
|
Yes
|
|
|
|
Fee for service, using Medicare upper limits
|
CN
|
|
Arizona
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
California
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Colorado
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Connecticut
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
|
Fee for service, additional payment for more than 10 miles
|
CN
|
|
District of Columbia
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Florida
|
|
Yes
|
$1/non-emergency trip
|
Non-emergency transports
|
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
|
|
2 trips/day
|
Fee for service
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
$3/trip if determined an inappropriate use, except for tribal members
|
Non-emergency transports
|
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Indiana
|
|
Yes
|
$.50-$2/non-emergency transport, depending on payment
|
Non-emergency transports or transports greater than 50 miles
|
|
Fee for service
|
CN
|
|
Iowa
|
|
Yes
|
$2/day for non-emergency transports
|
|
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/date of service for non-emergency trip
|
|
|
Reasonable charge with limits
|
CN & MN
|
|
Kentucky
|
|
Yes
|
|
|
|
Fee for service
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
|
|
Fee for service, using Medicare payment ceilings
|
CN & MN
|
|
Maine
|
|
Yes
|
$.50-$3/day, depending on payment, up to $30/month
|
|
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
|
Fixed wing transport
|
|
Fee for service
|
CN & MN
|
|
Minnesota
|
|
Yes
|
|
|
|
Fee for service using Medicare unadjusted base rate
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
$3/trip
|
Urgent fixed wing air ambulance transports
|
|
Fee for service, using a percentage of Medicare allowable payment as ceiling
|
CN
|
|
Missouri
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Montana
|
|
Yes
|
|
Non-emergency transports
|
All transports must meet specified medical necessity criteria
|
Fee for service
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
New Mexico
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
New York
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
|
|
|
Fee for service for private providers, cost based payment for public providers
|
CN & MN
|
|
North Dakota
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
|
|
|
Fee for service
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
South Dakota
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Tennessee
|
|
Yes
|
|
|
|
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
|
|
|
Fee for service
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
|
Fee for service
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
Non-emergency transports
|
|
Fee for service
|
CN & MN
|
|
Washington
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
|
|
Fee for service, using Medicare payment ceilings
|
CN & MN
|
|
Wisconsin
|
|
Yes
|
$2/non-emergency ambulance trip, $1/trip in specialized medical vehicle
|
|
|
Fee for service
|
CN & MN
|
|
Wyoming
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
|
Reasonable charge for off-island transport, federal Medicaid funds not claimed for on-island transport
|
CN
|
|
Northern Mariana Islands
|
|
Yes
|
|
|
|
|
CN & MN - See territory-specific FN
|
|
Puerto Rico
|
|
Yes
|
|
|
|
Fee for service for contracted staff
|
CN & MN
|
|
Virgin Islands
|
|
Yes
|
|
|
Air ambulance not covered
|
Reasonable charge
|
CN
|
