Crosswalk

2010 CMS 855 Forms Revisions
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1

2

3

Change
Bullets added; Removal of the HHABN
(discontinued in 2013); clear direction of the
purpose of the ABN is to transfer potential
financial liability to the beneficiary

Current Section

Overview

Added instructions for dual eligible beneficiaries
to comply with Title 18 of the Social Security Act;
Removal of Section 504 language since this is
included on the Form itself and was included on
the form instructions with the last submission
ABN Changes
Formating; Under Option 1, language added to
provide instruction for dual eligible/QMB
Completing the
beneficiaries
Notice

Reason
Improve readability; remove
language that was new at
the time with the prior PRA
submission
Update to Title 18 of the
Social Security Act; remove
language that was new at
the time with the prior PRA
submission
Improve readability;
compliance with Title 18 of
the SSA

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T:\PACKAGES\R101-150\131\2019\6 - Initial 30-day Incoming\12.11\ABN Crosswalk (080619)