What is an Advance Beneficiary Notice?
If your doctor or health care provider has a hunch that Medicare may not cover your service, they may give you an Advance Beneficiary Notice of Noncoverage (ABN). An ABN states that, based on your provider’s best estimate, Medicare may not provide coverage for the service you’re about to get. The notice must also list reasons why your provider thinks the service may not be covered.
For example, perhaps Medicare covered your service previously, but because you have reached the limit for the service under your Medicare benefits, your provider doesn’t think they’ll cover it again.
The ABN exists to transfer financial liability from the health care provider to you. If the health care provider does not notify you properly with an ABN when required by CMS, the provider could be on the hook for the bill.
What happens if you are given an Advance Beneficiary Notice?
Once you get an Advance Beneficiary Notice , you have the option to proceed with the service, but understand that if Medicare doesn’t pay for it, the tab is likely on you. If this is your choice, you’ll need to sign the notice and give it back to your provider. If you don’t, your provider may not furnish the medical device or carry out the service.
Alternatively, once you sign the ABN and receive the service, Medicare could end up covering the service, in which case, you can be thankful your provider was wrong (about your financial liability, anyway). If you paid before receiving the item or service, Medicare might reimburse you.
A couple of caveats on Advance Beneficiary Notices:
- An ABN is for beneficiaries with Original Medicare only. Those enrolled in Medicare Advantage are not given these notices.
- ABNs apply to items or services under the umbrella of Original Medicare. You will never receive an ABN for prescription drugs that aren’t covered by your Part D plan.
- CMS doesn't require an ABN for services that are never covered by Medicare, such as cosmetic surgery or routine dental work, but providers may still issue one if they choose to. Not sure what’s covered? Medicare.gov has a search tool for that.
- You should never get an ABN before an emergency situation.
What should you do if you are not given an Advance Beneficiary Notice?
If you were not given a “properly written and delivered” Advance Beneficiary Notice (ABN) but should have been according to CMS, you may not be financially liable for the item or service.1
“Properly written and delivered” refers to a lot of CMS rules, but here’s the gist:
- An ABN must be given in advance—meaning with enough time for you to consider your options—not immediately before a procedure.
- The notice must explain why Medicare probably won’t cover the item or service.
- You must get an opportunity to ask questions and get answers from the provider before you sign.
If you didn’t get an ABN in the right manner (or at all) when CMS requires one, you can file an appeal and possibly receive a reimbursement for the service or item. To file an appeal, follow the directions on your Medicare Summary Notice (MSN).
Sources
1. CMS.gov, “FFS ABN”
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