The Waiver Form Says Medicare Might Not Pay: Read the ABN Before You Sign Anything

The supplier hands you a form and says it is routine. Sometimes it is. The form is the Advance Beneficiary Notice, usually called the ABN. It exists for one situation: the supplier thinks Medicare may not pay for an item, and it wants you to know that before the item arrives. Read it while your parent is still in the hospital, before the delivery is on the porch.

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What the form is asking you to decide

An ABN is a written notice that Medicare may decide an item is not reasonable and necessary for your parent's condition. CMS publishes the form, and every supplier uses the same basic boxes. The boxes are worded closely to these three choices. Option one: you want the item and agree that the supplier may bill Medicare, knowing you may owe the cost if Medicare says no. Option two: you want the item but do not want Medicare billed, so you pay for it yourself. Option three: you do not want the item. Find the option you are being asked to tick before you read anything else, so you know what the rest of the page is for.

Check the item before you check a box

Compare the item name on the form with the item on your parent's doctor's order. If the form names a different product, a different size, or a different code, ask the supplier to explain the difference in writing. Read the reason printed on the notice. Ask the supplier to say that reason in plain words, and ask which Medicare coverage rule they believe applies. A reason you cannot repeat back is a reason to ask again.

Look for the estimated cost line. If it is blank, ask for the estimate in writing before you decide anything. Ask whether the form covers an item still to be delivered or one that has already arrived, because that changes what you are signing for.

Find out whether your parent has Original Medicare or a Medicare Advantage plan. The ABN is a Original Medicare form. Medicare Advantage plans handle coverage questions through their own approval process, so the plan's member line on the back of the insurance card is the place to confirm which paperwork applies.

Who signs, and what you keep

Only the person who can make this choice should mark a box and sign. If your parent cannot make it, check the paperwork the family already holds for who is allowed to decide for them. Do not sign a blank form, and do not sign one with the boxes still open. If the supplier says the choice must be made right away, ask what happens if you say you need to check with the doctor first, and ask for that answer to be written on your copy.

Ask for a copy you can keep, and put it with the discharge papers. The signing line should match the name on the form, and the notice should not be left with the supplier alone.

Questions to ask the supplier before you sign

Ask what the item is, exactly, and whether it matches the doctor's order. Ask what the estimate is under each option, and ask what happens next if Medicare denies the item under the option where Medicare is billed. Ask whether the doctor's office can send a note explaining why the item is needed, and ask who on the supplier's side will answer if the question comes up after delivery.

Compare the paper before you decide

Put the ABN beside the doctor's order and the discharge plan. If the item is on the order and the reason on the notice does not match what the doctor wrote, that gap is the thing to take back to the doctor's office. If the answers you get do not make sense to you, call the number on your parent's insurance card and ask the plan to explain what Medicare would decide and what the plan would decide.

The notice is one page, but it is the page that says who pays if the answer changes. Keep the copy with the other papers, and keep it where the next person who takes over the paperwork will find it. For the rules this article is built on, see the Sources page.