Medicare Advantage denied my parent's rehab or nursing-home stay. What can we do?
If the facility issued a Notice of Medicare Non-Coverage (NOMNC), you can request a fast-track appeal from the BFCC-QIO by noon of the day before coverage ends, and coverage continues while the QIO decides. If the plan denied the admission or the stay outright, request a reconsideration from the plan and ask for it to be expedited.
What to do, in order
- Step 1
Find which notice you have
A NOMNC means services are ending; a denial letter means the plan refused the admission or continued stay. Each has its own path.
- Step 2
NOMNC: call the QIO immediately
The number is on the notice. Request by noon of the day before the end date shown (42 CFR 422.626; 405.1200). The facility must give the QIO the records, and the plan must give you a detailed notice explaining why.
- Step 3
Denial: request an expedited reconsideration
Ask the plan for an expedited (72-hour) reconsideration when a delay could seriously jeopardise health. If the plan upholds, it must forward the case automatically to the Independent Review Entity.
- Step 4
Argue the right standard
MA plans must use Medicare's coverage criteria and consider the individual, not just an algorithm (42 CFR 422.101(b), (c)). Skilled care can be needed to maintain function, not only to improve it (Jimmo v. Sebelius).
The deadline that applies
Fast-track (NOMNC) appeal: by noon of the day before the termination date on the notice (42 CFR 422.626). Standard reconsideration of a plan denial: 60 calendar days after you receive the notice, and receipt is presumed 5 days after the date on it (42 CFR 422.582); expedited requests are decided within 72 hours. The date on the notice controls.
Calculate your date →Documents to gather
- The NOMNC or denial notice
- The facility's discharge summary and therapy notes
- The physician's order for continued skilled care
- Any hospital discharge paperwork showing the qualifying stay or admission basis
Go deeper
Related questions
Does my parent have to leave while the appeal is pending?
Not during a timely fast-track appeal: coverage continues until the QIO decides. If the QIO agrees with the plan, liability generally starts the day after the termination date on the notice.
What is the 'three-day rule'?
Original Medicare requires a three-day inpatient hospital stay before covered SNF care. Most MA plans waive it, but check the plan. Observation status days do not count as inpatient.
Can the plan use an algorithm to decide?
It may use tools, but since 2024 MA plans must base medical-necessity decisions on the individual's circumstances and Medicare coverage rules, and cannot deny solely on an algorithm's output (42 CFR 422.101(c)).
Sources
- 42 CFR 422.626, fast-track appeals of MA service terminations
- 42 CFR 405.1200 to 405.1206, expedited review of provider service terminations
- 42 CFR 422.101(c), Medicare Advantage medical-necessity decisions must consider the individual
- 42 CFR 422.582, Medicare Advantage request for reconsideration
- Medicare.gov, claims and appeals
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