What Is a Medicare Advance Beneficiary Notice (ABN)?
An Advance Beneficiary Notice (ABN) is a formal notification that Medicare may not pay for a certain item or service. ABNs are important because they help you make informed Medicare coverage decisions and prepare for any costs you might incur.
Medicare covers many items and services. Medicare doesn’t cover everything, however, and depending on the health care services you need, you may be required to pay for those items and services yourself.
When your doctor believes Medicare will not pay for a medical item or service, they may ask you to sign what’s called an Advance Beneficiary Notice (ABN). When you sign an ABN, you acknowledge that you’re willing to accept financial responsibility if Medicare denies payment.
It’s important to understand any ABNs you receive so you can make informed decisions and prepare financially for any costs you might incur.
If Medicare does cover your medical service or device, a Medicare Supplement (also called Medigap) plan may be able to help pay for out-of-pocket costs like Medicare copays, deductibles, coinsurance and more.
When Does Medicare Issue An Advance Beneficiary Notice?
The Centers of Medicare & Medicaid Services (CMS) issues advance beneficiary notices to make you aware when you may be personally responsible for paying for a medical service.
For example, you might receive an ABN if Medicare may not pay for a procedure performed for your specific health condition, or Medicare may not cover it as frequently as you want it. You might also receive an ABN for experimental procedures and services.
You won’t receive an advance beneficiary notice if it’s for an item or service that Original Medicare (Part A and Part B) never covers such as routine foot care, hearing aids, dentures, or cosmetic surgery.
ABNs are only used for beneficiaries enrolled in the Medicare Fee-for-Service (FFS) program, that is, beneficiaries who are enrolled in Original Medicare.
You won’t receive an advance beneficiary notice if you’re enrolled in a Medicare Advantage (Medicare Part C) plan, which are offered by private insurance companies. You also won’t receive an ABN for prescription drugs covered by a Medicare Part D prescription drug plan. If you have either type of plan, you can check directly with your plan carrier (insurance company) to find out how your service or medicine may or may not be covered by your plan.
What Types of Providers and Suppliers Issue Advance Beneficiary Notice?
You might receive an advance beneficiary notice from:
- A skilled nursing facility (for example, if your care or long-term stay might not be covered under Medicare Part A or if you require custodial care)
- A hospital (for example, if all or a portion of your hospital stay might not be covered under Medicare Part A)
- A fee-for-service (FFS) provider (for example, if you want to receive specialized medical care, ambulance services, certain blood tests, or home health aide services that may not be covered under Medicare Part B).
What’s Included on an Advance Beneficiary Notice?
Advance beneficiary notices may look differently depending on what type of provider or supplier issues it to you, but they all typically include the items or services that Medicare will not cover, reasons for non-coverage and the estimated cost of each non-covered item and service.
Your provider or supplier must follow detailed requirements from Medicare in terms of when and how they give you the ABN. If they don’t follow these requirements, the ABN may not be valid.
How Long Is an Advance Beneficiary Notice (ABN) in Effect?
An ABN remains in effect after valid delivery if there haven’t been any changes to the care described in the original notice and no changes to your health status that would require a change in the subsequent treatment for your non-covered condition.
If either of those considerations have changed, the ABN may no longer be in effect.
An ABN may also no longer be in effect if there are changes in Medicare coverage guidelines for the items or services in question. For example, there could be updates or policy changes that mean Medicare now covers something that it doesn’t cover before.
Does an Advance Beneficiary Notice Mean Medicare Definitely Won’t Pay?
No. An ABN is not an official denial of coverage. It simply means Medicare may not pay.
You won’t have a definitive answer until your provider or supplier submits the claim to Medicare. If Medicare does ultimately deny the item or service, you also still have the right to appeal that denial.
No matter what, you should always check with your doctor about whether your service will be covered by Medicare before you receive any health care services.
What Should I Do If I Receive an Advance Beneficiary Notice?
If you receive an ABN, you have three options in terms of how you can respond.
- First, you can continue to receive the items or services that Medicare may not cover, and you can ask your provider or supplier to submit the claim for processing. In this case, your provider or supplier may ask you to make a payment up front.
- Second, you can continue to receive the items or services that Medicare may not cover and tell your provider or supplier not to submit a claim. In this case, you may need to pay out-of-pocket, and you won’t have the option to appeal.
- Third, you can tell your provider or supplier that you don’t want the items or services that may not be covered.
If you don’t sign an ABN, your provider or supplier may not furnish the item or service you want.
What Happens If My Provider Doesn’t Give Me an ABN When They Should Have?
If your provider doesn’t give you an advance beneficiary notice when they were required to do so, you may be relieved of your financial responsibility to personally pay for the item or service. However, this isn’t the case if your provider or supplier can demonstrate that they did not know or could not reasonably have been expected to know that Medicare would not make payment.
It’s always a good idea to ask about potential costs in advance so you can make an informed decision.
If Medicare does cover your service or item, you could have help paying for some of the out-of-pocket Medicare costs you may face, such as deductibles, copays, coinsurance and more. A Medicare Supplement plan can help fill the “gaps” of Original Medicare coverage, helping to protect you from surprise medical bills.
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