Effect of Other
Insurers/Payers
If a beneficiary is eligible for both Original Medicare and Medicaid (dually
eligible) or is covered by Original Medicare and another insurance program or
payer (such as waiver programs, Office on Aging funds, community agencies
(e.g., Easter Seals) or grants), ABN requirements still apply. For
example, when a beneficiary is a dual eligible and receives home health
services that are covered only under Medicaid, but are not covered by Medicare
for one of the reasons listed in Table 1; an ABN must be issued at the initiation of this care to inform the beneficiary that
Medicare will likely deny the services.
Some States have specific rules regarding HHA completion of liability notices
in situations where dual eligible beneficiaries need to accept liability for
Medicare noncovered care that Medicaid will cover. Medicaid has the
authority to make this assertion under Title XIX of the Act, where Medicaid is
recognized as the “payer of last resort” (meaning other Federal programs like
Medicare (Title XVIII) must pay in accordance with their own policies before
Medicaid assumes any remaining charges)
On the ABN, the first check box under the “Options” section indicates the
choice to bill Medicare and is equivalent to the third checkbox on the outgoing
HHABN. HHAs serving dual eligibles should comply with existing HHABN State
policy within their jurisdiction as applicable to the ABN unless the State
instructs otherwise.
Note: If a State has issued a directive to select the third checkbox on the
HHABN, HHAs must mark the first check box when issuing the ABN.
Where there is no State specific directive, HHAs are permitted to instruct
beneficiaries to select Option 1 on the ABN when a Medicare claim denial is
necessary to facilitate payment by Medicaid or a secondary insurer. HHAs may add
a statement in the “Additional Information” section to help a dual eligible
better understand the payment situation such as, “We will submit a claim for
this care to your
other insurance,” or “Your Medical Assistance plan will pay for this care.”
HHAs may also use the “Additional Information” on the ABN to include agency
specific information on secondary insurance claims or a blank line for the
beneficiary to insert secondary insurance information. Agencies can pre-print
language in the “Additional Information” section of the notice.
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