If your Medicare Advantage plan says it will stop paying for rehab in a skilled nursing facility, you can ask for a fast appeal. You should get a "Notice of Medicare Non-Coverage" at least 2 days before covered services end, and Medicare.gov says to follow its instructions no later than noon the day before the end date. An independent reviewer decides whether coverage should continue.
What notice should I get?
Medicare.gov says that in settings like a skilled nursing facility, you should get a notice called the "Notice of Medicare Non-Coverage" (NOMNC) at least 2 days before your covered services end. It lists:
- The date your covered services will end.
- How to ask for a fast appeal.
- The phone number for the reviewer.
The facility usually hands it to you or your family. If your parent is the patient, ask staff to give a copy to you too. Write the date and time you got it on the top.
If you hear "Medicare won't cover after Friday" but haven't seen this notice, ask for it.
What to say to the facility:
"I understand coverage for [patient name]'s rehab may end. Can I please have a copy of the Notice of Medicare Non-Coverage? I'd like to see the end date and the appeal instructions."
Who decides a fast appeal?
Medicare.gov says an independent reviewer, called a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), decides whether your covered services should continue. Depending on your state, it's run by Commence or Acentra. The phone number is on the notice.
This works the same way for people in Medicare Advantage Plans and Original Medicare. If you have a plan, Medicare.gov says the BFCC-QIO will notify the plan.
What is the deadline?
Medicare.gov says to follow the instructions on the notice no later than noon the day before the termination date listed on it.
Example: If the notice says coverage ends on Thursday, call the BFCC-QIO by noon on Wednesday.
That can be less than a day. If you're a family member, ask your parent now whether they want to appeal, and keep the notice where you can find it.
How do I ask for the fast appeal?
- Call the number on the notice. It's the BFCC-QIO.
- Say you want a fast appeal of the decision to end skilled nursing facility services.
- Give the patient's name, the facility's name, and the end date on the notice.
- Write down the date, time, name of the person you spoke with, and any reference number.
What to say to the BFCC-QIO:
"I'm calling to ask for a fast appeal for [patient name] at [facility name]. Their Medicare Advantage plan, [plan name], says skilled nursing services end on [date]. We don't think they're ready. They still need [daily physical therapy / wound care / help learning to walk safely]. Can you tell me what happens next and when I'll hear back?"
What happens after I call?
Medicare.gov says that by the end of the day the provider hears from the BFCC-QIO, the provider will give you a "Detailed Explanation of Non-Coverage." That paper explains why coverage is ending. Read it, and if something in it is wrong, tell the reviewer.
The BFCC-QIO then reviews the medical records. Medicare.gov says it decides by close of business the day after it gets the information it needs. You can ask for copies of materials sent to the reviewer.
What will I owe during the appeal?
Medicare.gov says that if the reviewer decides services should end, you won't be responsible for paying for skilled nursing services provided before the end date on the Notice of Medicare Non-Coverage.
If you stay past that date and the reviewer agrees coverage should end, you may owe for the days after it. Ask the facility for the daily private-pay rate in writing so you know what's at stake. If the reviewer sides with you, coverage generally continues under your plan's normal rules.