Situations in Which a SNF ABN Should Be Given

70.2 - Situations in Which a SNF ABN Should Be Given (Rev. 4198; Issued: 01-11-19; Effective: 04-30-18; Implementation: 04-30-18) A. Triggering Events A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. The following describe the three triggering events for a SNF ABN: EVENT DESCRIPTION Initiation In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary. Reduction In the situation in which a SNF proposes to reduce a beneficiary’s extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary. Termination In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services. B. Effect of Other Insurers/Payers Some States have specific rules established regarding completion of liability notices in situations where dual-eligibles need to accept liability for Medicare non-covered care that will be covered by Medicaid. Medicaid has the authority to make this assertion under Title XIX of the Act, where Medicaid is recognized as the “payer of last resort”, meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid picks up any remaining charges. If the patient is a Medicare-Medicaid dual-eligible and a triggering event occurs, the SNF needs to give the beneficiary a SNF ABN. On a practical basis, physician-prescribed items or services continue without interruption or reduction when a patient changes “payer eligibility” from Medicare to Medicaid. From the Medicare coverage vantage-point, however, there is a reduction or termination when Medicare, which has been paying, stops paying. In other words, there is a triggering event, which underlies the change in “payer eligibility.” In these instances, a SNF ABN must be issued to transfer financial liability to the beneficiary.