Medicare waiver/Advance Beneficiary Notice (ABN): Frequently asked questions
What is a Medicare waiver/Advance Beneficiary Notice (ABN)?
An ABN is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving certain items or services, notifying you:
- Medicare may deny payment for that specific procedure or treatment
- You will be personally responsible for full payment if Medicare denies payment
An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare's decision.
If I receive an ABN form, what are my options?
You have the option to receive the items or services or to refuse them. In either case, you should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.
If you choose to receive the items or services:
- You must check "OPTION 1".
- Sign and date the form.
- The claim will be sent to Medicare. You may be billed while Medicare is making its decision.
- If Medicare does pay, you will be refunded any payments that are due to you.
- If Medicare denies payment, you will be personally responsible for full payment.
- You will have the right to appeal Medicare's decision.
If you choose NOT to receive the items or services:
- You must check "OPTION 2".
- Sign and date the form.
- Your claim will not be sent to Medicare.
Although Medicare may not pay for your items or services, there may be good reasons for your physician recommending them. You should notify your doctor of your refusal.
What if I refuse to sign an ABN, but I want the items or services anyway?
If you refuse to sign, one of two actions will take place:
- Mayo Clinic may decide not to provide the items or services.
- A second person will witness your refusal to sign the agreement, and you will receive the items or services. However, you may be held liable because you have been notified of the likelihood of a Medicare denial.
When I am liable for payment because I signed an ABN, how much can I be charged?
When you sign an ABN and become liable for payment, you will have to pay for the item or service yourself, either out of pocket or by some other insurance coverage that you may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between you and Mayo Clinic. If this is a concern for you, you may want to ask for a cost estimate before you sign the ABN.
Why do I routinely receive an ABN for certain items or services?
Certain items or services that are covered by Medicare are only covered up to a certain number of times within a specified amount of time. Examples of these "frequency limited" services include laboratory tests, some preventive screening tests and vaccinations. If you receive an ABN that gives a frequency limit as its reason, it means that Medicare will not pay if you exceed that limit on the service.
Do ABNs mean that Medicare is reducing coverage?
No. ABNs do not operate to reduce coverage at all. Only if and when Medicare does deny the claim, do you become liable for paying personally for the service or item. If Medicare decides to pay the claim, you have lost nothing by signing the ABN.
Who do I contact if I have more questions about my Medicare coverage?
For more information about your Medicare coverage, please contact Medicare directly:
- May 21, 2016