When you’re not well, it can be reassuring to know you’re in good hands, like when you’re receiving care in a skilled nursing facility (SNF). But if you’re on Medicare and are told that your stay at an SNF is ending, yet you don’t feel well enough to fend for yourself at home, what can you do?
The good news is that you do have rights in this situation. However, your next steps will depend on whether you have Original Medicare or an Advantage plan. Here’s how to navigate both situations.
What to do if you have Original Medicare
With Original Medicare, you are entitled to coverage for a skilled nursing facility. During each benefit period, for the first 20 days, you pay nothing. For days 21 through100, your co-insurance is $185.50 per day, and beyond that, you pick up the entire tab.
If you reach the limit on your care or don’t qualify for care, you won’t necessarily get a written notice (it’s not required) and you can’t appeal. The onus is on you to keep track of your benefit period days.
However, when Medicare coverage ends because SNF care is deemed no longer medically necessary, not reasonable, or custodial (rather than medical), you do have the right to appeal. In these cases, you’ll get a Notice of Medicare Non-Coverage (NOMNC) from your provider no later than two days before your services end. (If you don’t receive this notice, ask for it.)
- QIO appeals. If you feel that your care shouldn’t be ending, ask for a fast appeal. The NOMNC will tell you how to do that. (The notice might also call it an immediate or expedited appeal.) A fast appeal is key to your continued stay.
File your appeal no later than noon of the day before your services are ending. Once you’ve asked for a fast appeal, an independent reviewer called a Quality Improvement Organization (QIO) will decide if your services need to continue.
After you file the appeal, your provider should give you a Detailed Explanation of Non-Coverage. This explains in writing why your care is ending and lists any Medicare coverage rules related to your case. The QIO will usually call you to get your opinion about it. You can also send a written statement.
The QIO is supposed to make its decision no later than two days after your care was set to end. Your provider can’t bill you before the QIO makes its decision.
If you miss the deadline for a fast appeal, you have up to 60 days to file a standard appeal with the QIO. If you’re still receiving care, the QIO should make its decision as soon as possible after receiving your request. If you’re no longer receiving care, it must decide within 30 days.
No matter which kind of appeal you end up making, be sure the QIO has any information that bolsters your case. Ask your doctor to submit anything to the QIO that will help support your need for continued care.
If your QIO appeal is successful, your Medicare coverage for the SNF continues for as long as your doctor continues to certify it.
- QIC appeals. What happens if the QIO denies your appeal? You don’t have to give up. You can take it to the next level by making a fast appeal to the Qualified Independent Contractor (QIC) by noon of the day following the QIO’s decision. The QIC should decide within 72 hours. Your provider can’t bill you for continuing care until the QIC decides. However, if you lose your appeal, you’ll be responsible for all costs, including the costs incurred during the 72 hours the QIC deliberated.
If you miss the deadline for a QIC fast appeal, you have up to 180 days to file a standard appeal with the QIC. In this case, the QIC must decide within 60 days. If the appeal to the QIC is successful, your Medicare coverage remains intact for as long as your doctor continues to certify it.
- OMHA appeal. If your appeals have been denied, you can still appeal to the Office of Medicare Hearings and Appeals (OMHA) within 60 days of the date on your QIC denial letter as long as your care meets a certain cost threshold ($180 in 2021). OMHA should decide within 90 days. If your appeal to the OMHA is successful, Medicare will continue coverage for as long as your doctor certifies it.
- Further appeals. There’s yet another play to try if you’re denied. Appeal to the Medicare Appeals Council within 60 days of the date on your OMHA denial letter. There’s no timeframe in which the Medicare Appeals Council must decide. If this appeal is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.
The buck stops with an appeal to the Federal District Court within 60 days of the date on your Medicare Appeals Council denial letter. You can file as long as the contested services would amount to $1,760 or more (as of 2021). There’s no mandatory timeframe for the Federal District Court to decide.
What to do if you have a Medicare Advantage plan
Every Medicare Advantage plan is different, so it’s best to check with yours about if and how it will notify you if you are in danger of using up your services and losing coverage.
Generally, if you’re enrolled in a Medicare Advantage plan and your provider thinks your SNF care won’t be covered by your plan any longer, your provider must send you a Notice of Medicare Non-Coverage (NMNC). You should get this notice no later than two days before your care is set to end. If you don’t agree with the SNF’s decision, you can then file an appeal.
- QIO appeals. You can file an appeal much like you would if you were covered by Original Medicare. An appeal must be filed no later than noon of the day before your care is set to end and the QIO must decide no later than the day your care is scheduled to end. If your appeal is successful, your care continues under Medicare.
If you lose that appeal, you can file another appeal with the QIO, which will have different staff review your second appeal. You have 60 days following the QIO’s initial denial to make that move, and the QIO must respond within 14 days of receipt of your appeal. If you’re still in the hospital, you can’t be charged until the QIO makes its ruling. But if you lose, you’re responsible for all costs, including those incurred during the time the QIO deliberated.
- OMHA appeal. Even if you lose, you can keep going. You have the right to file an appeal with the Office of Medicare Hearings and Appeals (OMHA) within 60 days of the date on your QIO denial letter as long as the cost of your care meets a certain threshold ($180 in 2021).
- Further appeals. If you still don’t get the results you want, you can appeal to the Medicare Appeals Council within 60 days of the bad news from the OMHA.
Lost again? The last hope is an appeal to the Federal District Court within 60 days of your thumbs-down from the Medicare Appeals Council, as long as the amount in question is $1,760 or more (as of 2021).
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