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What is a Medicare Waiver?

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  • Written By: Sandra Koehler
  • Edited By: Bronwyn Harris
  • Last Modified Date: 04 September 2014
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A Medicare waiver, also known as an ABN, or Advance Beneficiary Notice, is a document received before treatment services or equipment are given. The waiver is to notify the Medicare-covered patient of possible non-coverage. In effect, it states that the patient has be made aware of the fact that the services or medical devices requested may not be covered under the patient’s Medicare plan. In that event, the patient is responsible to pay any expenses incurred during the treatment or for the equipment purchased.

Medicare is broken down into parts. Each part, A, B and D, covers different things. For example, part A generally covers things like hospitalization, skilled nursing facilities and hospice care. Part B generally covers medically necessary physician services, preventative care and some medical equipment. Part D provides optional prescriptions coverage. But just because you have the Medicare insurance plan to cover the expected treatment course does not mean it will be covered fully.

On occasion, services or equipment deemed medically necessary by your healthcare provider may not be covered. Many alternative medical practices and vision care are examples of medically relevant treatments that are not covered by Medicare. Other times, Medicare may cover the expenses with limitations. For example, some services are only covered a certain number of times within a certain time frame. This is where the Medicare waiver comes into play.

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A Medicare waiver does not mean the patient is being refused treatment or equipment. It also does not mean the treatment is not medically necessary. It simply means that the expenses incurred may be higher than the patient’s normal Medicare co-pay, as Medicare typically does not cover 100 percent of the costs.

The Medicare waiver gives the patient the right to accept the possibility that the expenses incurred may be out-of-pocket. It also gives you the right to refuse the treatment or equipment. Though given a Medicare waiver does not mean there is no possibility of getting the services or equipment covered as the patient is offered the right to appeal the decision of non-payment.

If a patient receives a Medicare waiver, or ABN, the first step is to contact the physician prescribing the service or device to be used. There may be some alternatives to consider. The physician can also play an important role in the appeal process to prove the treatment course is medically relevant and can assist the patient in recovery from a specific ailment or illness.

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Clairdelune
Post 3

@wander - Yes, I agree, the Medicare waiver, along with the whole Medicare program, is complicated and hard to grasp. And the rules keep changing.

I've been told that it's better to go to the business office of your clinic for information about what Medicare covers in a particular situation. Often, your physician just isn't up to date on Medicare coverage.

As far as the waiver goes, it seems very unfair to leave the patient hanging. He has to decide whether to have the procedure with the possibility of being responsible for some big bills. Or, refuse treatment and then "who knows what."

I think that many improvements need to be made in the Medicare system. Nevertheless, it is a pretty good system and many Americans are thankful to have it.

drtroubles
Post 2

If you are offered a Medicare waiver does anyone know if you can request that your doctor find you an alternative service or medicine that is more completely covered?

I know that with drugs for example that there are many generic versions available that may be covered under medical plans, where their brand name versions are not.

In the case of medical procedures, having a choice of testing would a great option for those struggling to cover bills. As often, there is more than one way to do things.

I think patients should be able to choose from a variety of options as they are paying for a service in the long run.

wander
Post 1

I wonder how many people are caught unaware when signing a Medicare waiver and then ending up with huge medical bills that they can't afford to pay.

I think this system is dangerous and takes advantage of patients that may not know all of their rights in regards to medical services. Often these waivers are full of legalize and are difficult to understand.

Also, a patient may feel that they must sign because there is no way for them to get their medication or medical equipment otherwise.

I think that a system that tells patients exactly what is being paid for should be mandatory. Knowing that there is a possibility of non-coverage is one thing, knowing that you will have to pay $50,000 is something else entirely.

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