Have you had your eye on a svelte powerchair, but Medicare will only cover a portion of the cost?

You might feel like a kid with his face pressed against the toy shop window on Christmas, staring at toys he wants but can’t buy.

Alas, wheelchair users with Medicare do have an option to score their dream ride- the ABN form. We break down the Advance Beneficiary Notice definition and process here.

What is the CMS R131/ABN Form?

Centers For Medicare & Medicaid Services logo

The Advance Beneficiary Notice of Noncoverage (ABN) is an official Medicare form issued by providers to be filled out and signed by the Medicare beneficiary in question.

When a beneficiary seeks medical services or equipment, Medicare covers the cost, but only if it is deemed medically necessary.

Suppose a beneficiary prefers a different service/product not fully covered by Medicare. In that case, they might be able to fill out a CMS ABN form and pay the difference, but only for specially coded items, which include upgrades.

The ABN form printable can easily be downloaded and filled out right in your supplier’s office.

How Does the Medicare ABN Process Work?

A person filling out the CMS ABN Form

To better understand the CMS ABN form, let’s first look at an example.

Say you want a Group 4 powerchair that costs $6,900, but Medicare approved a Group 3 powerchair that costs $5,900.

The beneficiary then has the right to ask the provider for an ABN to purchase still the $6,900 chair with Medicare covering the stated $5,900 and the beneficiary paying the remaining $1,000 difference out of pocket.

Note once again that this only applies to coded items approved for the beneficiary by Medicare. Medicare may refuse to fully cover a service or product for some of the following reasons:

  • The service or product is experimental or investigational.
  • Medicare doesn’t consider it safe or effective.
  • It’s not an indicated method for diagnosis or treatment.
  • It goes over the limit of services Medicare allows for a diagnosis in a certain period.

Medicare ABN Rules for Providers

Not everyone gets a stab at the Advance Beneficiary Notice Form. Since it is a standard Medicare process, suppliers are trained on how and when to issue one to a patient, which means certain criteria must be met.

Here are some reasons why a supplier issues an ABN notice:

  • A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) is a private insurance company that works with Medicare to provide coverage. An ABN can be filled if it deems an item not “medically necessary” for the patient.
  • A supplier can apply for Advance Determination of Medicare Coverage (ADMC) for approval before the item is sent to the patient. If this request is denied, then they’ll issue an ABN.
  • Sometimes a supplier might want to standardize inventory and grants the lucky beneficiary an item upgrade at no extra cost.
  • A Medicare Advance Beneficiary Notice can be issued if the patient is currently using the same product or something similar.

Advance Beneficiary Notice of Noncoverage for Private Insurance

If you have private insurance, you might think that this article doesn’t apply to you, but that’s not necessarily true.

Some insurance companies offer a similar process to the ABN Advanced Beneficiary Notice. The best way to find out if this is an option for you is to contact your insurance to discuss what they can bring to the table.

Are There Other Options Besides a Medicare ABN Form?

A woman filling out an Advanced Beneficiary Notice form being assisted by another woman

Perhaps you were granted an Advanced Beneficiary Notice of Noncoverage approval. However, you still don’t have the funds to cover the difference, or you just don’t believe you should have to fork over the money.

If your provider suggests an Advanced Beneficiary Notice, here are some questions you can ask if you are on the fence.

  • Situation One: Your provider mentioned that the service or equipment you’re interested in is medically necessary but still offers an ABN Notice Medicare. Simply inquire as to why you need to sign an ABN since Medicare should fully pay if it’s necessary unless it’s excluded from coverage.
  • Situation Two: You can appeal Medicare’s rejection of coverage with the help of your provider. Ask if they’d be willing to write a letter to Medicare justifying your needs.

Final Thoughts: Advance Beneficiary Notice of Noncoverage Form (ABN)

The ABN Form 2021 is a Medicare beneficiaries’ right to acquire the service or equipment they desire, paying the difference that Medicare won’t cover.

Understandably, not everyone has the funds to upgrade a wheelchair, even if they have access to an Advance Beneficiary Notification.

But if you’re new to the process and prefer a different model to what Medicare will cover, then the CMS Advance Beneficiary Notice is a solid option to help get the chair you want.

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