Your Protections

If you have Original Medicare, your doctor, other health care provider, or supplier may give you a written notice if they think Medicare won’t pay for the items or services you’ll get. This notice is called an “Advance Beneficiary Notice of Non-coverage,” or ABN. The ABN lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.

What can I do if I get this notice?

On the ABN, you’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

• Option 1: You want items or services that Medicare may not pay for. Your provider or supplier may ask you to pay for these items or services now, but you also want your provider or supplier to submit a claim to Medicare.
  • If Medicare denies payment: You’re responsible for paying. However, since a claim was submitted, you can appeal to Medicare.
  • If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).

  Remember, an ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if a claim is submitted and Medicare denies payment. Your ABN has clear directions for getting an official decision about payment from Medicare, and for filing an appeal if Medicare won’t pay.

  You may get an Advance Beneficiary Notice of Noncoverage if you’re getting an off-the-shelf back or knee brace that’s included in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. Medicare might not pay for an off-the-shelf back or knee brace from a supplier that isn’t a competitive bidding contract supplier .

  What are the types of notices?

  Home Health Agency Advance Beneficiary Notice: Home health agencies must give you an ABN before you get any items or services that Medicare may not pay for because:

  • The items or services aren’t considered medically reasonable and necessary.
  • The care is only non-skilled, personal care, like help with bathing or dressing.
  • You aren’t homebound.
  • You don’t need skilled care on an intermittent basis.

  Medicare doesn’t require an ABN for items or services that Medicare never covers.

  “Home Health Change of Care Notice” (HHCCN): Home health agencies must give you an ABN or a HHCCN when they reduce or stop providing home health services or supplies because:

  • The home health agency makes a business decision to reduce or stop giving you some or all of your home health services or supplies.
  • Your doctor changed your orders, which may reduce or stop giving you certain home health services or supplies that Medicare covers.

  The HHCCN lists the services or supplies that will be changed, and it gives you instructions for what you can do if you disagree with the change.

  The home health agency isn’t required to give you a HHCCN when it issues the “Notice of Medicare Non-coverage” (NOMNC).

  “Notice of Medicare Non-Coverage” (NOMNC): Your home health agency will give you a NOMNC at least 2 days before all covered services end. If you don’t get this notice, ask for it. This written notice will tell you:

  • When your covered services will end.
  • How to appeal if you think the services are ending too soon.
  • How to contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to ask for a fast appeal.

  If you decide to ask for a fast appeal, call the BFCC-QIO within the timeframe listed on the notice. After you request a fast appeal, you’ll get a second notice with more information about why your care is ending. The BFCC-QIO may ask you questions about your case. To help your case, ask your doctor for information, which you can submit to the BFCC-QIO.

  “Detailed Explanation of Non-coverage” (DENC): Your home health agency will give you a DENC when the BFCC-QIO tells your home health agency that you've requested a BFCC-QIO review of your case. The DENC will explain why your home health agency believes that Medicare will no longer pay for your home health care.

  "Skilled Nursing Facility Advance Beneficiary Notice" (SNFABN): A Skilled Nursing Facility (SNF) will issue you a SNFABN if there's a reason to believe that Part A may not cover or continue to cover your care or stay because it isn't reasonable or necessary, or is considered custodial care .

  The SNFABN lets you know that Medicare will likely no longer pay for your services. If you choose to get the services that Medicare may not cover, you don't have to pay for these services until a claim is submitted and Medicare officially denies payment.

  However, while the claim is processed, you must continue paying costs that you would normally have to pay, like the daily coinsurance and costs for services and supplies Medicare generally doesn't cover.

  "Hospital Issued Notice of Noncoverage" (HINN): Hospitals use a HINN when Medicare may not cover all or part of your Part A inpatient hospital care. This notice will tell you why the hospital thinks Medicare won't pay, and what you may have to pay if you keep getting these services.