CMS Issues Guidance on Completing the ABN for Dual Eligibles
November 15, 2013 04:17 PM
The National Association for Home Care & Hospice has been hearing from members with concerns regarding completing the Advanced Beneficiary Notice (ABN) Form CMS –R-131 for dual eligible beneficiaries.
Of particular concern is that none of the options the beneficiary has to choose from clearly states when Medicaid will be paying for the care. The Centers for Medicare & Medicaid Services (CMS) clarified that agencies should include information regarding coverage by Medicaid in the “Additional Information” section of the form and that the forms may be pre-typed. CMS also clarified that if another payer is to cover the full cost of care the amount listed in section “F Estimated Cost” may be $0.
NAHC posed the following question to CMS:
The language in the new form is different than the old Option Box 1 where by it is not clear when or whether another insurer will be billed. This is of particular concern regarding the dual eligible, who might refuse the service for fear that they will be billed. For example, in the statement “Note: “If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.”
Additionally, not all states require that a claim be submitted to Medicare leaving the beneficiary to choose option 2 - “I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed” The only solution is for agencies to add clarifying language in “H. Additional information”. Does CMS have other recommendations?
Also, are agencies still required to estimate the cost for services when another insurance will be billed and it is known that they will cover all of the costs? May the agencies enter $0 in these cases in “F. estimated cost”?
CMS’ responded with the following information:
There is no new or different process, and HHAs should continue going by State recommendations for billing dual eligibles and in regard to ABN issuance. We have had many questions on this and plan to publish language to clarify this section in the near future. Meanwhile, you can offer agencies this additional guidance:
Option choices for dual eligible will vary depending on your State Medicaid directive. Please follow your State Medicaid office’s recommendations. If a Medicare denial is needed in order to get Medicare to pay as secondary, the patient should be instructed to choose Option 1. If your State Medicaid office does NOT want a claim filed with Medicare prior to filing a claim with Medicaid, the patient should choose Option 2. HHAs may direct dual eligibles on choosing the correct option box according to State directives. HHAs are permitted to pre-type information in the “Additional Information” area for ABNs issued to dual eligibles to help them understand that Medicaid will pay for the service. For example, if Option 1 is selected based on State guidance, you can include a statement saying “Checking Option 1 will allow Medical Assistance to pay for this care” or something similar, in accordance with State policy. If Option 2 is chosen based on State guidance, but the HHA is aware that the State sometimes asks for a Medicare claim submission at a later time, the HHA must add a statement in the “Additional Information” box such as “Medicaid will pay for these services. Sometimes, Medicaid asks us to file a claim with Medicare. We will file a claim with Medicare if requested by your Medicaid plan.”
Yes, since this is the cost estimate for which the beneficiary is responsible $0 is certainly acceptable.