Medicare Advance Beneficiary Notice of Noncoverage

Medicare doesn’t pay for everything. Thus, if there’s a possibility Medicare won’t pay for an item or service, a provider should let their patient know ahead of time. The Advance Beneficiary Notice (ABN) informs the patient that Medicare may not cover the care they request. From there, the patient can choose whether or not to proceed, accepting financial responsibility if there is ultimately no coverage.

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What is an Advance Beneficiary Notice?

An Advance Beneficiary Notice (ABN) of Noncoverage is a written waiver of liability given to Medicare beneficiaries. You’ll receive this notice from your provider if Medicare may not cover your service. With this in mind, it’s up to you whether to take on the financial burden should you be responsible for paying out-of-pocket.

An ABN lists which items or services may not receive coverage. Additional information includes reasons for potential nonpayment and cost estimates for which you’d be responsible. Then, after reviewing this information, you must select an option and provide your signature.

The purpose of an ABN is to transfer possible financial liability from Medicare to the patient if necessary. Yet, if Medicare never covers an item or service, there is no requirement for the provider to furnish an ABN.

Advance Beneficiary Notice of Noncoverage Options

Should you receive an ABN, you’ll need to choose from three options before signing:

  1. Agree to proceed with the care regardless of whether Medicare pays, telling your provider to submit a claim to Medicare
  2. Agree to proceed with the care and tell your provider not to bill Medicare, so you pay out-of-pocket
  3. Decline the care and avoid any potential costs

When choosing an option, consider how necessary you deem the care. Will this item or service make your life easier or offer other benefits? Also, determine whether you’ll be comfortably able to pay the full amount you may owe. When you weigh your health and budget needs, you’ll come to the right conclusion.

Filing an Appeal Related to an Advance Beneficiary Notice

If your provider doesn’t follow Medicare’s rules for how to supply an ABN, you might not be responsible for out-of-pocket costs. In this case, you should file an appeal.

An ABN must:

  • Include the exact service(s) and/or item(s) the patient has received
  • Include a potential reason for denial of a claim
  • Be received and signed before the date of service
  • Be easy to read and understand
  • Not be given to the patient during an emergency

Occasionally, a patient won’t receive an ABN before care when their provider should consider Medicare might not pay. In this case, the patient may not need to pay out-of-pocket if Medicare denies coverage for something they don’t explicitly omit.

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In any case, you may file an appeal if your Medicare Summary Notice reflects a denial of payment – receiving an ABN doesn’t stop you. Thus, prior to care, you should ask your provider to bill Medicare before billing you, checking the applicable box on the ABN. Certainly, if the provider doesn’t attempt to bill Medicare for anything, there can be no denial of payment to dispute. Though, you can’t file an appeal if you receive an ABN but refuse care, as there is no claim in that scenario.

Could I Get an Advance Beneficiary Notice if I Have Medicare Advantage?

You won’t receive an ABN if you have a Medicare Advantage plan. The Centers for Medicare & Medicaid Services (CMS) prohibits the use in Advantage plans of the same ABNs Original Medicare patients receive.

Other Advance Beneficiary Notices

There are two types of ABNs that are specific to Part A of Medicare. A skilled nursing facility (SNF) will issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) if Part A may not cover, or may cease to cover, a patient’s stay or care. Reasons for Medicare not covering SNF care include lack of necessity or if the care is custodial in nature, which Medicare doesn’t cover.

Unless or until the claim results in denial, the patient isn’t responsible to pay for the SNF services. Yet, they will still be responsible for coinsurance and other uncovered Medicare costs.

The other type of ABN is Hospital Issued Notice of Noncoverage (HINN). Hospitals use HINNs when Medicare may not totally cover inpatient care. Like a regular ABN, a HINN explains why Medicare may not pay and lists the out-of-pocket costs that would result from a denial.

How to Get Help with an Advance Beneficiary Notice

You may not know where to turn if Medicare denies your claim. But if you have a policy with us, our Client Care team will help you with your appeal every step of the way. If you aren't a client, you'll need to contact your carrier, doctor, or agent directly.

Our agents can also help you enroll in a Medicare Supplement policy to reduce your out-of-pocket costs, as well as Part D for prescription drugs. To start plan-shopping, call the phone number above or fill out our online rate form for a comparison of premiums in your area.

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David Haass

  • Chief Technology Officer

David Haass is the Chief Technology Officer and Co-Founder of Elite Insurance Partners and He is a member and regular contributor to Forbes Finance Council and stay up-to-date with the latest Medicare trends and changes. He holds a Bachelor of Science in Business Administration and Management from the University of Florida.


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