On March 13, 2026, the Centers for Medicare & Medicaid Services (CMS) released an updated version of the Advance Beneficiary Notice of Non-Coverage, Form CMS-R-131, commonly known as the ABN. Providers who serve fee-for-service Medicare beneficiaries must transition to the updated ABN no later than May 12, 2026. The updated ABN Form is important because many organizations either use ABNs incorrectly or not at all, taking on avoidable compliance risk or missing the opportunity to realize the value of services patients will pay for.
While the update is framed primarily as a usability improvement, it presents a timely opportunity for all providers and suppliers who participate in Medicare to evaluate their compliance posture. For organizations that already use ABNs routinely, this alert serves as a reminder to review and renew existing practices to ensure compliance. For those that have not yet integrated ABNs into their workflows, this is the time to do so.
What is the ABN Form and Why Does It Matter?
The ABN is a standardized notice that Medicare providers must issue to beneficiaries in certain circumstances before furnishing an item or service. Its core function is straightforward: the ABN informs a Medicare beneficiary that Medicare may not cover a particular item or service and that the beneficiary may be personally responsible for the cost. By issuing a valid ABN, the provider preserves the right to bill the beneficiary in the event that Medicare denies the claim.
ABN issuance is generally required whenever a provider has reason to believe that Medicare will deny payment for an item or service that Medicare would otherwise typically cover. Common scenarios include situations where a service may not meet Medicare’s “reasonable and necessary” standard, where frequency limitations may apply, or where documentation may not support coverage. If the provider fails to issue a valid ABN when required, the provider generally cannot hold the beneficiary financially responsible and must absorb the cost of the denied service.
It is equally important to understand what an ABN does not do. An ABN does not authorize a provider to charge a beneficiary for services that are otherwise covered by Medicare, nor does it permit a provider to bundle covered services into membership fees, access charges, or similar arrangements. This remains a key enforcement focus, particularly for organizations considering or offering concierge, direct-care, or hybrid service models.
ABNs as a Strategic Compliance Tool
There continues to be confusion around the role ABNs can play in a provider’s broader Medicare strategy. In many cases, providers assume they must formally opt out of Medicare to offer enhanced or non-covered services. This is often not the case. A properly implemented ABN process can provide meaningful flexibility within the Medicare program without the operational and financial consequences associated with opting out.
When used appropriately, ABNs can support a range of legitimate objectives. They allow providers to offer services that may fall outside Medicare’s coverage criteria while giving beneficiaries a meaningful choice about whether to proceed on a self-pay basis. They also allow providers to continue participating in Medicare while still being able to serve patients who wish to pay out of pocket for specific items or services. In this way, ABNs can serve as an important tool in structuring hybrid or concierge-style offerings within a Medicare-compliant framework.
There are, however, important limits that providers must make note of. Providers must not overextend the ABN’s purpose to shift liability to a beneficiary absent a genuine, service-specific basis for believing Medicare will deny the claim. Routine or defensive use of ABNs for every service, regardless of the likelihood of denial, is not permitted and can itself create compliance risk. Moreover, ABNs do not permit providers to charge for services that are in fact covered by Medicare, or to relabel covered services as “access,” “membership,” or administrative fees. This is an area that has been the subject of repeated enforcement attention.
Implementation Timeline
Providers are required to transition to use of the new ABN form by May 12, 2026. However, as a best practice, providers should begin using the updated form as soon as practical.
What CMS Changed in the New ABN
The updated ABN form includes several changes intended to improve beneficiary comprehension while reducing burden on providers. Key changes in the updated ABN include:
- Plain language revisions throughout the form. CMS has rewritten the notice using clearer, more accessible language to help beneficiaries understand their rights and financial exposure.
- Revised “Medicare Exclusions & Cost Table.” The table now uses simplified column headers- providing a more intuitive structure for identifying non-covered items and the basis for non-coverage.
- Updated beneficiary options language. The beneficiary’s three options, request Medicare billing and preserve appeal rights (Option 1), receive the service without Medicare billing (Option 2), or decline the service (Option 3), have been rewritten for clarity.
What Did Not Change; Key Compliance Reminders
The substantive framework governing ABN use has not changed. Since the underlying rules remain the same, this update presents an opportunity to revisit several requirements that are frequent sources of audit findings and repayment risk:
- ABNs must be issued whenever there is a reasonable expectation that Medicare will deny payment for an item or service that Medicare otherwise covers. The obligation is triggered by the provider’s knowledge or reasonable belief that Medicare will deny payment for an item or service that Medicare otherwise covers, not by certainty of denial.
- ABNs must be completed correctly and delivered timely. A valid ABN must (i) identify the specific items or services listed, (ii) provide a plain-language reason Medicare may not pay for each, (iii) include a good-faith cost estimate, and (iv) be delivered to the beneficiary far enough in advance of the service that there is time to consider the options and make an informed decision. An ABN presented at the time of service or after the service is generally invalid.
- The provider must review the ABN with the patient or their representative and answer any questions before the form is signed. Simply presenting the form for signature, without a discussion, does not satisfy CMS’s requirement.
- An ABN that is incomplete, untimely, or deficient, such as one where the provider pre-selects an option on behalf of the patient, is treated as if no ABN was issued at all. In these cases, the provider will bear the financial risk for any resulting Medicare denial.
What’s Next: For Organizations Already Using ABNs
If your organization currently issues ABNs as part of its Medicare operations, this update should prompt a targeted review. Recommend measures include:
- Transition to the updated ABN forms as soon as practical and no later than the stated implementation deadline.
- Review your existing workflows to confirm that ABNs are being issued at appropriate clinical and administrative trigger points rather than on a blanket or reflexive basis.
- Retrain front-line staff on proper completion, delivery, and patient communication procedures. Review your current practices to ensure that ABNs are issued timely to allow beneficiaries enough time to make an informed decision before services are provided.
- Evaluate high-risk service lines where denials are more likely to occur.
- If your organization operates a concierge or hybrid model, confirm that there is a clear and documented separation between covered and non-covered services and that ABNs are not being used to circumvent Medicare coverage obligations.
What’s Next: For Organizations Not Yet Using ABNs
If your organization bills to Medicare but does not currently have a formal ABN process in place, this update is an important signal to act. The absence of an ABN program means that when Medicare denies a claim, the organization will bear the financial consequences without the ability to seek payment from the beneficiary. Establishing a compliant ABN workflow now, including implementing staff training, clinical trigger identification, and documentation protocols, can materially reduce reimbursement risk and strengthen your organization’s overall Medicare compliance posture.
Recommended Next Steps
This update presents an opportunity for all providers to reassess their ABN practices comprehensively. Organizations tend to fall into one of two categories: (1) those that overuse ABNs defensively, issuing them broadly without a service-specific basis, and (2) those that underutilize them in situations where they could appropriately support patient choice and cost transparency. Neither approach is optimal, and both create unnecessary risk. This is the time to recalibrate. Getting ABNs “mostly right” is not sufficient. The gap between “adequate” and fully compliant (and strategically effective) use is where most financial exposure and enforcement risk arise. Strengthening ABN practices now will help ensure compliance, improve operational consistency, reduce audit risk, and better position your organization for today’s healthcare environment.
The updated ABN form and form instructions can be found on the CMS website here.
Leech Tishman has extensive experience working with providers to implement concierge models, review ABN practices, and refine Medicare billing strategies and compliance by identifying risk areas and opportunities for improvement. For assistance or additional information, please contact Harry J. Nelson at hnelson@leechtishman.com or Nancy Lam at nlam@leechtishman.com, attorneys in Leech Tishman’s Healthcare Practice Group. Moshe Bock, a Law Clerk with Leech Tishman’s Healthcare Practice Group, contributed to the research and drafting of this article.