Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.
The following are some examples of when an ABN can be used for non-covered services:
• Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
• Services paid for by a government entity other than Medicare
• Personal comfort items
• Routine eye care
• Dental care
• Routine foot care
ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.
An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.
CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.
If your provider asks you to sign an ABN, the document must:
• Give the name or description of the service they are providing
• Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: ‘Medicare does not pay for this test for your condition,’ ‘Medicare does not pay for this test as often as this (denied as too frequent)’, or ‘Medicare does not pay for experimental or research tests.’
• Give you the estimated cost of the service or procedure
• Provide you with three options, worded in the following ways:
o Option 1. ‘I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.’
o Option 2. ‘I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.’
o Option 3. ‘I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.’
The ABN will also have a place for additional information, such as a dated witness signature.
There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.
Some points to remember:
• Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.
• Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.
• If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurance may cover services that Railroad Medicare does not.