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:
