Traditional Medicare Advance Beneficiary Notices (ABNs)

Background

Most private insurance contracts allow providers and enrollees to obtain prior assurance that a claim will be covered. This is the case for many higher-cost services. But in some circumstances, the health plan may require preauthorization. MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). does not operate this way. MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). ’s standard for coverage is that care must be deemed “reasonable and necessary.” When providers recommend care for which they believe MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). might not pay (because it is not deemed reasonable and necessary), they must notify a traditional fee-for-service beneficiary that the service may not be reimbursable. The notice must be given both verbally and in writing. This advance beneficiary noticeAn ABN is a notice that a provider must give a Medicare beneficiary before delivering a service, if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. ( ABNAn ABN is a notice that a provider must give a Medicare beneficiary before delivering a service, if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. ) is intended to foster an informed discussion between the doctor and the beneficiary about whether or not to proceed with the service at the beneficiary’s expense. An ABNAn ABN is a notice that a provider must give a Medicare beneficiary before delivering a service, if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. is not required for services that are categorically excluded from MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). coverage, such as cosmetic surgery and experimental procedures.

An ABNAn ABN is a notice that a provider must give a Medicare beneficiary before delivering a service, if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. is not considered a private contract. Some providers have misused ABNs, asking beneficiaries to sign blanket notices promising payment far in advance without specifying the service. A blanket notice that does not specify the service does not fulfill the purpose of the ABNAn ABN is a notice that a provider must give a Medicare beneficiary before delivering a service, if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. or enable a beneficiary to make an informed choice each time a service is recommended.

As part of the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Modernization Act of 2003, Congress called for a system of prior determination in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). for certain items and services. The Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services published final rules for the new system in 2008. They state that beneficiaries or their providers may ask a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). administrative contractor about the coverage and cost of certain services and items. Prior-determination requests may be made only for physician services with the highest average allowed charges, or plastic and dental surgeries with a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Physician Fee Schedule amount of $1,000 or more. Many beneficiaries may not be aware of physician charges or their right to prior determinations.

TRADITIONAL MEDICARE ADVANCE BENEFICIARY NOTICES: Policy

TRADITIONAL MEDICARE ADVANCE BENEFICIARY NOTICES: Policy

Appropriate use of notices

The Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services (CMS) should prohibit routine or blanket use of advance beneficiary notices (ABNs) by providers. CMS should monitor the use of ABNs and sanction providers who use them inappropriately.

CMS should ensure that providers and beneficiaries are informed about the appropriate use of ABNs.

ABNs should clearly indicate the item or service for which MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). payment is in question, the reason the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). payment is in question, and why the provider believes the service is necessary. ABNs should require the signatures of both the provider and the beneficiary.

CMS should closely monitor the system of prior determination in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). to ensure that it is applied fairly and broadly.