What is an ABN in Medicare

Someone at the desk slides a form across and says Medicare might not cover this, so we need a signature. You are reading it standing up, with your coat on. The signature is not the part that matters.

What is an ABN?

An Advance Beneficiary Notice of Non-coverage is a written warning from your provider that Medicare may not pay. It lists the items or services your provider expects Medicare will not cover, an estimate of what they cost, and the reasons Medicare may refuse.

Those three contents are not optional decoration. A notice without an estimate, or without a reason, is missing something Medicare says the notice carries.

It applies to Original Medicare. Your doctor, other health care provider or supplier may give you one when they think Medicare will not pay for what you are about to get.

The most important thing it is not is a decision. Medicare states plainly that an ABN is not an official denial of coverage by Medicare, which means nobody has refused anything yet at the moment you are holding it.

It also belongs to a family. The same protections page names a Home Health Change of Care Notice, a Notice of Medicare Non-Coverage, a Detailed Explanation of Non-coverage, a Skilled Nursing Facility version and a Hospital Issued Notice of Noncoverage.

They arrive from different places and at different moments. What they have in common is that each one exists to tell you, in writing and in advance, that somebody expects Medicare to stop paying.

Why was I asked to sign one?

Because your provider expects Medicare to refuse this particular item or service. In its home health rules Medicare states that an ABN is not required for things Medicare never covers, so the notice signals a doubt about your case rather than a blanket exclusion.

That distinction is worth holding onto while you read the form. If a service were simply outside Medicare altogether, this piece of paper would not be the mechanism.

The reasons live on the notice itself. Medicare says the ABN lists the reasons why Medicare may not pay, alongside the items and the cost estimate, so the answer to why me is printed on the page in front of you.

Home health gives the clearest published example of what those reasons look like. An agency must give you an ABN before items or services Medicare may not pay for, and Medicare lists four grounds.

• The items or services are not considered medically reasonable and necessary
• The care is only non-skilled, personal care, like help with bathing or dressing
• You are not homebound
• You do not need skilled care on an intermittent basis

Read that list and a pattern shows up. Every reason is about your circumstances rather than about the service, which is why the same care can need a notice for one person and not another.

So the form is a prediction about you. That is uncomfortable, and it is also the reason it can be wrong and the reason an appeal exists at all.

What happens if I sign?

You tick one of three boxes, and that choice does the work. Signing says only that you read and understood the notice. The box you choose decides whether a claim is filed, whether you pay, and whether you keep the right to appeal.

Signing says only that you read and understood the notice.

Signing is not the decision. The box is. This is our reading rather than a rule stated in one place, and three of Medicare's own facts produce it.

Medicare says you will be asked to choose an option box and sign the notice to say that you read and understood it. It separately says Option 1 sends a claim to Medicare, so if Medicare denies payment you can appeal. And it separately says that under Option 2, because you asked your provider not to submit a claim to Medicare, you cannot file an appeal.

So the signature acknowledges and the tick decides. Those three facts are Medicare's. Reading them as one is ours.

Here is what each box produces.

The box you tick	What you get	Can you appeal
Option 1, bill Medicare	The service, and a claim is filed	Yes, if Medicare denies payment
Option 2, do not bill	The service, and no claim	No, because no claim was filed
Option 3, decline	Nothing, and no payment owed	No, because no claim was filed

The third column is the one nobody points at. Two of the three boxes end the matter permanently, and only one of them keeps a door open.

What if I refuse to sign?

No page read for this article says what happens if you sign nothing. What Medicare does publish is a box for declining: Option 3 says you do not want the items or services, you are not responsible for any payments, and no claim is submitted.

That gap is worth stating rather than filling. A reader standing at a desk with a form deserves to know which part is documented and which part is not, and this publication does not carry an outcome no government page states.

What is documented is that the notice is built around a choice. Medicare says you must choose one of the three options, so the form does not anticipate a fourth path where nothing is ticked.

Option 3 is the closest published thing to refusing. You do not get the items or services, you are not responsible for any payments, no claim goes to Medicare, and you cannot file an appeal.

Notice that Option 3 costs you the appeal too. Declining the service and declining to bill Medicare land in the same place on that column, because in both cases there is no claim for Medicare to rule on.

So the honest summary is short. There is a documented way to say no, it is a box rather than a blank form, and the price of it is the same as Option 2.

Does signing mean I must pay?

Not automatically, and not to Medicare. Under Option 1 you may be asked to pay now, and if Medicare later pays, your provider refunds what you paid, excluding copayments and deductibles. If Medicare denies, you are responsible. Option 3 leaves you owing nothing at all.

The refund detail is the part that surprises people. Paying up front under Option 1 is not a concession that the service is uncovered, and if Medicare pays, the money comes back minus the copayments and deductibles you would owe anyway.

Under Option 2 the payment is real and the review is gone. You may be asked to pay for the items or services now, and because no claim goes to Medicare there is nothing to overturn later.

One member of the notice family works differently and it is worth knowing if the setting is a nursing facility. With a Skilled Nursing Facility Advance Beneficiary Notice, if you choose to get the services you do not have to pay for them until a claim is submitted and Medicare officially denies payment.

That is not a free pass while the claim runs. Medicare states that during processing you must keep paying the costs you would normally have to pay, such as the daily coinsurance and the costs of services and supplies Medicare generally does not cover.

So the answer depends on the box and on the setting, and in the most common case the money is recoverable rather than spent.

Can I appeal after signing?

Only if a claim was submitted. An ABN is not an official denial by Medicare, and the right to appeal exists when a claim is filed and Medicare then denies payment. Option 1 preserves that. Options 2 and 3 remove it.

Medicare puts the reason in plain terms. There is nothing to appeal against until Medicare has actually made a decision, and Medicare only makes one when a claim reaches it.

The instructions are on the form. Medicare states that your ABN has clear directions for getting an official decision about payment from Medicare, and for filing an appeal if Medicare will not pay.

If a denial does come, the window is shorter than people assume and it does not start when you open the envelope. In Original Medicare you have 120 days from the date of receipt of the initial determination, and receipt is presumed to be 5 calendar days after the date printed on the notice unless there is evidence otherwise.

So the sequence under Option 1 runs like this. A claim is filed, Medicare decides it, and if the decision goes against you the clock starts about five days after the date on the letter.

That whole sequence is unavailable to anyone who ticked one of the other two boxes, which is why the form is worth reading sitting down.

What this means for you

An ABN is a prediction, not a refusal. Your provider expects Medicare to say no to this particular item for you, and Medicare has not decided anything at the point you are handed the form.

The signature is the smaller half. It confirms you read and understood the notice. The box above it decides whether a claim reaches Medicare at all, and that is the thing that decides whether an appeal is ever possible.

Option 1 is the only box that leaves a claim behind. Option 2 buys the service and closes the review. Option 3 declines the service and also closes the review, because in both cases Medicare never sees a claim.

Money moves differently from rights. Under Option 1 you may pay up front and be refunded if Medicare pays, minus copayments and deductibles. In a skilled nursing facility you may not have to pay until an official denial, while still owing the daily coinsurance throughout.

For how the appeal itself works after a denial, read this publication's article on how to appeal a Medicare denial. For the notice that later tells you what Medicare actually paid, read the article on the Medicare Summary Notice.

FAQ

Does signing an ABN mean I have agreed to pay?

Signing says something narrower than that. Medicare states that you are asked to choose an option box and sign the notice to say that you read and understood it, so the signature is an acknowledgement rather than a promise.

What decides the money is the box. Under Option 1 your provider may ask you to pay now, and if Medicare later pays, they refund what you paid, not including your copayments or deductibles.

If Medicare denies payment under Option 1, you are responsible for paying. Under Option 3 you are not responsible for any payments at all, because you have declined the items or services.

Which box protects my right to appeal?

Option 1, and only Option 1. Medicare states that under Option 1 a claim is submitted to Medicare, so if Medicare denies payment you can appeal.

Under Option 2 you take the items or services but ask your provider not to submit a claim, and Medicare's own words are that because you asked them not to submit a claim, you cannot file an appeal.

Option 3 declines the service, no claim is submitted, and you cannot appeal either. The reason is the same in both cases: an appeal is a challenge to a Medicare decision, and Medicare only makes a decision when a claim reaches it.

What if I just do not sign the form at all?

None of the pages read for this article says what happens then, and this publication will not invent an answer while you are standing at a desk holding a pen. What is documented is that Medicare expects a choice: you must choose one of the three options. Option 3 is the published way to say no, and it is specific.

You do not want the items or services that Medicare may not pay for, you are not responsible for any payments, a claim is not submitted to Medicare, and you cannot file an appeal. So there is a documented route to declining, and it costs you the same appeal right that Option 2 costs.

Why did I get an ABN for something Medicare normally covers?

Because the notice is about your situation rather than about the service. Medicare states, in its home health rules, that it does not require an ABN for items or services that Medicare never covers, which means the form exists for the grey area rather than for things that are always excluded.

The published home health reasons show the pattern: the care is not considered medically reasonable and necessary, the care is only non-skilled personal care like help with bathing or dressing, you are not homebound, or you do not need skilled care on an intermittent basis. Every one of those is a fact about you, not about the treatment.

Is an ABN the same as being denied by Medicare?

No, and Medicare says so directly: an ABN is not an official denial of coverage by Medicare. It is your provider's expectation, written down in advance, that Medicare will not pay. Nothing has been decided at the point you are handed the form, which is exactly why the appeal route still exists if a claim is submitted and then refused.

Medicare adds that your ABN has clear directions for getting an official decision about payment from Medicare and for filing an appeal if Medicare will not pay, so the form itself is the instruction sheet for challenging the prediction it contains.

How long would I have to appeal if Medicare does deny it?

In Original Medicare the window is 120 days, and it does not begin the day you read the letter.

CMS states that the appellant has 120 days from the date of receipt of the initial claim determination to file a redetermination request, and that the notice is presumed to be received 5 calendar days after the date of the notice unless there is evidence to the contrary.

So the count starts about five days after the date printed on the page rather than on the day it arrived in your hands. That window only exists at all if a claim was submitted, which brings you back to which box was ticked when the ABN was signed.