Got Medicare: Are You Covered?
By Alan Bestall
When a Medicare Beneficiary arrives at a healthcare provider’s point of service there may be certain written notices that must be provided to them explaining their coverage under Medicare. Often, due to confusion about the requirements, or the patient’s state of mind, a transparent description of coverage, or the lack of it, results, later, in costly out of pocket charges to beneficiaries.
The most common notice is the Advanced Beneficiary Notice (ABN) issued for Part B service under Fee for Service, Original Medicare, Hospice, and Religious Non-healthcare Institutions. There is a separate form for Home Health and Skilled Nursing Facility services and items.
If a provider believes Medicare may not pay for a service or item an ABN must be issued. Reasons for issuing the ABN include the provider believing that the service or item may not be medically necessary. The ABN allows a beneficiary to make an informed decision on whether to obtain the service or item and to accept possible financial responsibility if Medicare does not pay for the service. ABN’s do not have to be issued in a medical emergency or under coercive circumstances, but may be issued in an emergency room if the beneficiary is visiting for what are determined to be non-emergent circumstances.
The Health Insurance Counseling & Advocacy Program sees several cases a month where patients have not been notified properly, or at all. They receive bills for services after Medicare has denied coverage. Many times these matters can be resolved in favor of the patient.
Patients need to ask if the provider believes the service will be covered under Medicare Part B. If presented with a form (CMS-R-131) they need to be allowed time to consider the language it lists in non-coercive circumstances and not have the feeling that they are under duress to complete and sign the form. Notices that are not on the correct form may not be enforceable. Patients need to be aware of their rights and understand what is being proposed for their care before accepting treatment and service items.
For specific help on issues that develop after service, contact Elder Law & Advocacy’s Health Insurance Counseling and Advocacy Program at: (858) 565-8772.
Alan Bestall, J.D., is a registered counselor for HICAP at Elder Law & Advocacy and has an extensive background in healthcare and legal matters.