You have rights if your skilled nursing facility (SNF) decides to reduce your care because it believes that Medicare will no longer cover it. Be aware that the process is slightly different depending on whether you have Original Medicare or a Medicare Advantage Plan. Also, note that there is a separate process if you are appealing because your care is ending (see My Skilled Nursing Facility Is Discharging Me Too Early, What Should I Do?).
If you have Original Medicare, and your SNF decides to reduce services prescribed by your doctor because it believes that Medicare will no longer cover these services, it should give you a notice explaining why services are being reduced. If you are in an SNF, you should receive a notice indicating that Medicare may deny part of your care. This notice is often called a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). Each notice will ask you to choose one of the following three options:
- Request care and ask the SNF to bill Medicare (demand bill). If Medicare denies coverage, you have the right to file an appeal. If your appeal is unsuccessful, you may be responsible for the cost of care. An SNF may refuse to demand bill.
- Request care but agree to pay for the care out of pocket.
- Turn down care. You can look for another SNF that might cover the needed care.
Remember, you have the right to a demand bill if your care is being reduced because your SNF doesn’t believe Medicare will cover it. If you ask an SNF to demand bill Medicare, you cannot be billed until Medicare makes a coverage decision.
If you are in a Medicare Advantage Plan and your SNF is reducing your care because it believes Medicare will no longer cover these services, you typically have to ask your plan for a fast (expedited) review of this decision.
Read More: After Leaving a Skilled Nursing Facility How Does Medicare Coverage and Care Coordination Work?
Learn About: Under What Circumstances Does Medicare Cover Skilled Nursing Facility Care?
Return to: Medicare In-Depth
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