Your rights if your skilled nursing facility (SNF) believe Medicare will reduce coverage for your SNF care will depend upon whether the SNF intends to reduce the services ordered in your plan of care or will agree to provide you all of the care your doctor has ordered anyway. The plan of care is the set of services that the SNF agrees to give you when it assesses your needs. Medicare may not consider all services in the care plan necessary for the same length of time.
- If the SNF plans on reducing your care because it thinks Medicare will not pay for all of the care your doctor has ordered, you will need to either agree to the reduction or find another SNF.
- If the SNF believes that Medicare will reduce the amount of care it will cover but is still willing to provide you with all of the care your doctor ordered, you have the right to ask the SNF to bill Medicare for the care that Medicare may not cover. This is called demand billing. The SNF must give you a document called a Skilled Nursing Facility Beneficiary Notice (SNF ABN) or a SNF denial letter. SNFs have a choice as to which document they choose to use. The SNF ABN or denial letter will explain why services will be reduced. In this case, the SNF ABN or denial letter is only for the services that the SNF does not think Medicare will pay for.
You will need to make a choice by checking a box on the notice to either:
- Turn down care—you can look for another Medicare-certified SNF or
- Accept care, ask the SNF to bill Medicare and/or other insurance (demand bill) and agree to pay the cost of the care received if Medicare denies coverage.
If you demand bill, the SNF cannot bill you until Medicare makes its decision to pay for your care or not. The Medicare Summary Notice (MSN), which you receive on a quarterly basis, will show Medicare’s decision. If Medicare denies payment, you can appeal by following the instructions on your MSN.
Note: If the SNF does not provide you an ABN and Medicare later denies care because of lack of medical necessity, you typically will not owe the SNF for your care.