Medicare ABN Explained for Seniors: Before You Sign

What Has Changed

For ABNs used now, three details matter. First, CMS announced the redesigned CMS-R-131 and required it starting May 12, 2026 in a March 2026 update. The current ABN sample expires March 31, 2029. CMS says the revision uses plainer language and improved usability. You can confirm the current version on the CMS ABN page and its updated ABN tutorial.

Second, the current instructions spell out special steps for people who have both Medicare and Medicaid, including QMB coverage. Third, CMS still expects a good-faith cost estimate, but in unusual cases the form may state that no cost estimate is available. An unexplained blank cost field is different from a stated inability to estimate.

What an ABN Really Means

Medicare explains that an ABN is a written notice a doctor, provider, or supplier may give someone with Original Medicare when it expects Medicare will not pay for a particular item or service. The notice should show the care at issue, why Medicare may not pay, and an estimated cost. See Medicare’s ABN protections page.

The word “may” matters. An ABN gives the provider’s opinion before Medicare has made a payment decision. If you select Option 1, the provider submits a claim and Medicare decides whether to pay.

A valid mandatory ABN is generally used when Medicare normally covers the type of item or service but the provider expects payment to be denied in your particular case. Common reasons include medical-necessity rules, frequency limits, or other coverage requirements.

CMS also allows providers to use an ABN voluntarily for items or services Medicare never covers. In that voluntary situation, the current instructions say you do not need to choose an option box or sign the notice. This distinction matters because a courtesy notice for something Medicare excludes is not the same as a mandatory liability notice for care Medicare might otherwise cover.

Check the Form Before Signing

CMS says the provider should give the ABN before the item or service, review it with you, answer your questions, and give you enough time to make an informed choice. You can ask for a copy after the form is completed and signed.

A signature does not mean you agree that Medicare should deny the claim. It means you received and understood the notice and made a choice. Your appeal rights depend mainly on whether a claim is submitted.

What Options 1, 2, and 3 Do

The current ABN gives three choices. The consequences are different, so do not treat Option 2 as a middle ground.

Option 1: Get the care and bill Medicare

Choose this when you want the item or service and want an official Medicare payment decision. The provider may ask most beneficiaries to pay before Medicare decides. If Medicare pays, the standard form says the provider refunds what you paid beyond applicable copayments or deductibles. The payment rules are different for certain non-participating providers that do not accept assignment, so ask how payment and any refund would work in your case.

When the claim is processed, compare the result with your Medicare Summary Notice. Our Medicare Summary Notice guide explains how to read the decision and the amount Medicare says you may owe.

Option 2: Get the care without billing Medicare

This means you want the care but are telling the provider not to send a claim to Medicare. You are responsible for the charge, and because Medicare never receives a claim, you normally have no Medicare payment decision to appeal.

Option 3: Decline the listed care

This means you do not want the item or service listed on the ABN. The provider does not furnish it under that choice, so there is no Medicare claim and no appeal about whether Medicare would have paid.

If You Have Medicaid or QMB

This is one of the most important parts of the current instructions. If you are enrolled in Medicare and Medicaid, including QMB coverage, CMS says you should be instructed to select Option 1 so Medicare can adjudicate the claim. The instructions also say the provider cannot bill you when the ABN is delivered and must wait for both Medicare and Medicaid adjudication before billing you.

You can read the rule in the current ABN instructions. Our dual-eligible Medicare guide explains how Medicare and Medicaid can work together.

QMB does not make every noncovered service free. Federal QMB protection prevents Medicare providers and suppliers from billing QMB members for Medicare Part A or Part B deductibles, coinsurance, and copayments on Medicare-covered items and services. But after Medicare and Medicaid process a properly noticed noncovered service, patient liability can depend on whether you have full Medicaid, your state’s Medicaid rules, and the type of service. CMS explains the cost-sharing protection on its QMB billing page.

If a provider bills you for ordinary Medicare cost-sharing even though you have QMB, see our QMB billing protections guide. If Medicare costs are hard to afford and you are not sure whether you have QMB, Medicare’s Medicare Savings Programs page explains state programs that may help, and our Medicare Savings Programs guide gives a plain-language overview.

When a Standard ABN Is Not the Right Notice

Do not assume every Medicare warning notice is CMS-R-131. CMS maintains different notices for different settings. Its beneficiary notices list includes the Skilled Nursing Facility ABN, Hospital-Issued Notices of Noncoverage, the Notice of Medicare Non-Coverage, and other forms.

• Medicare Advantage: Standard ABN rules are for Original Medicare. If your Medicare Advantage plan refuses coverage or payment, use the plan’s organization determination and appeal process. See Medicare’s health plan appeals page and our Medicare Advantage appeals guide.
• Skilled nursing facility Part A: A skilled nursing facility generally uses the SNF ABN for Part A liability, not the standard CMS-R-131 used for certain Part B items and services.
• Care is ending: Home health, skilled nursing, hospice, and some rehabilitation settings use fast-appeal notices when covered care is ending. Our Medicare fast appeals guide covers that different deadline-driven process.
• Home health coverage dispute: An ABN may appear in some home health situations, but care reductions and terminations can involve other notices. Our home health denial guide helps sort out the next step.

Signs the ABN May Have a Problem

• The box was pre-selected. CMS says provider pre-selection invalidates the notice, unless staff marks your choice at your request because you cannot physically do it and documents that assistance.
• The reason is generic. The notice should give a reason that actually applies to each listed item or service.
• The service is unclear. You should be able to tell what care is at risk. For repetitive care, the frequency or duration may matter.
• The cost field is simply blank. CMS expects a good-faith reasonable estimate. In unusual situations the notifier may say no estimate is available, but that is different from leaving the issue unexplained.
• You were given it after the care. Mandatory ABNs are supposed to be delivered before the item or service, with enough time to make an informed choice.
• You were rushed during an emergency. CMS says ABNs are never required in emergency situations.
• You cannot get a copy. Ask for one. You will need it if a billing or appeal problem develops.

What to Do After You Sign

If you selected Option 1, keep the ABN and watch for the claim. You can check processed claims in your secure Medicare account. When the claim appears, read the MSN carefully. Medicare says the MSN is not a bill; it shows what was billed, what Medicare paid, and the maximum amount you may owe.

If Medicare denies the item or service and you disagree, follow the appeal deadline and instructions printed on the MSN. Medicare’s Original Medicare appeals page explains the five appeal levels. At the first level, you can use the MSN instructions or the Redetermination Request form. Medicare’s appeals forms page also lists forms for later levels and for appointing a representative.

Ask the ordering doctor for a short note explaining why the care was medically needed when that is the issue. Include useful records rather than a large stack of unrelated papers.

If You Chose Option 1 but No Claim Appears

Option 1 requires the notifier to submit a claim to Medicare. If you do not see one, call the billing office and ask when it was sent. Medicare says providers and suppliers generally must file Medicare claims for covered services, and Medicare claims usually must be filed within 12 months of the date of service unless an exception applies.

If the provider refuses or cannot file, Medicare’s claim filing page explains the rare cases when a beneficiary may submit a claim. The form is the CMS-1490S claim form. Do not wait until the filing limit is almost over. Call Medicare if the claim is missing and ask for the deadline that applies to your service.

Keep These Papers and Use These Scripts

Keep one folder, envelope, or digital folder with:

• Your completed ABN
• The provider’s written cost estimate
• The itemized bill and receipts
• Your Medicare Summary Notice
• Doctor orders or notes supporting medical need
• Medicaid or QMB proof, if applicable
• Names, dates, and reference numbers from calls

If a family member needs Medicare to discuss your personal claim details, Medicare’s other forms page includes the Authorization to Disclose Personal Health Information form.

Reality Checks and Common Mistakes

• Do not pick Option 2 by accident. It stops the claim from going to Medicare and usually removes the normal appeal path.
• Do not assume QMB erases every bill. QMB blocks Medicare cost-sharing on Medicare-covered items and services, but valid charges for noncovered care can involve different rules.
• Do not treat payment now as a denial. For most beneficiaries, Option 1 allows the provider to request payment before Medicare decides. Keep the receipt.
• Do not confuse the MSN with a bill. Compare the provider bill with the Medicare decision before paying a disputed balance.
• Do not use ABN rules for Medicare Advantage. Contact the plan and follow the plan’s written coverage decision and appeal process.
• Do not miss the claim or appeal deadline. Save the ABN, track the claim, and follow the date shown on the Medicare notice.

Official Help and Useful Resources

Use Medicare’s coverage search to check whether Medicare generally covers an item or service. A coverage page cannot decide your individual claim, but it can help you prepare questions for the provider.

For billing and claim questions, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Medicare lists these numbers on its contact Medicare page.

For free one-on-one counseling, use the SHIP state locator. SHIP counselors are not insurance-company sales agents and can help with Medicare rights, billing problems, and appeals.

If you are unsure which agency handles the issue, Medicare’s rights help page explains when to contact Medicare, your plan, SHIP, or other oversight programs.