What is an Advance Beneficiary Notice (ABN)?

What is an Advance Beneficiary Notice?

It's a written notice, Form CMS-R-131, that warns you before you get care that Medicare may not pay. If you have Original Medicare, your doctor, other health care provider or supplier may give you an ABN if they think Medicare won't pay for the items or services you'll get. The ABN lists those items or services, an estimate of their costs and the reasons why Medicare may not pay, so you can decide whether to get them knowing you may have to pay.

An ABN isn't an official denial of coverage by Medicare. It shifts the possible cost to you: if you choose to get the items or services listed, you're agreeing to pay if Medicare doesn't.

When does a provider have to give me an ABN?

CMS says that when Medicare is not likely to cover a specific item or service, health care providers and suppliers must use the ABN to let you know you may be financially liable before you get it. The providers required to use it include:

• Physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B, including independent laboratories.
• Hospice providers and religious non-medical health care institutions paid only under Part A.
• Home health agencies providing care under Part A or Part B.
• Medicare inpatient hospitals and skilled nursing facilities, for Part B items and services (they use other notices for Part A).
• The provider must give you the ABN before the items or services, review it with you and answer your questions before you sign, deliver it far enough in advance for you to consider your options, give you a copy if you ask once it's completed and signed, and keep a copy on file.
• An ABN is never required in emergency situations, and providers don't have to (but still may) give you one for services Medicare never covers; in that case, you don't need to choose an option or sign.

What are my choices on an ABN?

You must choose one of three option boxes, and the provider can't choose for you (an ABN with an option already selected by the provider isn't valid):

• Option 1: you want the items or services, and you want the provider to submit a claim to Medicare. The provider may ask you to pay now. If Medicare denies payment, you're responsible for paying, but because a claim was submitted you can appeal. If Medicare does pay, the provider refunds what you paid, not including copayments or deductibles.
• Option 2: you want the items or services but don't want a claim submitted to Medicare. You may be asked to pay now, and because Medicare isn't billed, you can't file an appeal.
• Option 3: you don't want the items or services. You aren't responsible for any payments, no claim is submitted, and you can't file an appeal.
• If you want some but not all of the items listed, the provider can use more than one ABN, one for each choice.

What happens after I sign an ABN?

Signing says you've read and understood the notice. If you chose Option 1, Medicare makes an official payment decision, which you'll see on your Medicare Summary Notice (MSN). If Medicare denies payment, you can file an appeal once you get the MSN showing the item or service, following its directions. You'll have to pay if Medicare decides the items or services aren't covered and no other insurer is responsible for payment. See How do I appeal a Medicare denial?.

Are there other Medicare notices like the ABN?

Yes. Medicare.gov lists other non-coverage notices for specific settings:

• Home Health Change of Care Notice (HHCCN): a home health agency gives you an ABN or an HHCCN when it reduces or stops your home health services or supplies because the agency made a business decision to do so or because your doctor changed your orders.
• Notice of Medicare Non-Coverage (NOMNC): your home health agency gives you this at least 2 days before all covered services end. It explains when services end and how to ask for a fast appeal if you think they're ending too soon.
• Skilled Nursing Facility ABN (SNFABN): a skilled nursing facility issues this if there's reason to believe Part A may not cover, or continue to cover, your care or stay because it isn't reasonable or necessary or is considered custodial care. If you keep getting the services, you don't pay for them until a claim is submitted and Medicare officially denies payment, but you keep paying costs you'd normally pay, like the daily coinsurance.
• Hospital-Issued Notice of Noncoverage (HINN): hospitals use this when Medicare may not cover all or part of your Part A inpatient hospital care.

Do Medicare Advantage plans use ABNs?

The ABN is a notice for Original Medicare. If you're in a Medicare Advantage Plan, you have the right to ask the plan in advance whether it covers a certain service, drug or supply by contacting the plan and submitting a pre-service request for an organization determination. If the plan denies your request, its response includes instructions to file a timely appeal.