The instructions for beginning a termination of care appeal with a Medicare Advantage plan are very similar to beginning an appeal with Original Medicare. For more on Original Medicare appeals, please click here.
If you are enrolled in a Medicare Advantage (private health) plan and are losing services from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) because your plan believes Medicare will not pay for your care any longer, you can appeal.
Your doctor or other health care provider should give you a notice called a Notice of Medicare Non-Coverage (NOMNC). The NOMNC tells you when care is scheduled to end and how you can contact a Quality Improvement Organization (QIO) to appeal. You should appeal to the QIO if you think you need more care. The QIO is an independent group of medical professionals that contracts with Medicare to ensure people with Medicare get good quality care.
You should typically receive the NOMNC no later than two days before care is set to end. If you begin your appeal with the QIO in time, your care must continue during your appeal and you cannot be charged for care until the QIO makes its decision.
Note: You will only receive the NOMNC if your care is ending because your provider has determined you are no longer eligible for care under Medicare coverage rules. You will not get the notice if you are losing coverage for another reason. For example, if a skilled nursing facility does not have the staffing or capacity to care for you, or you have exhausted the Medicare covered days you can remain in the facility, you will not get the NOMNC. In these cases, you must find another facility or agency in your plan’s network.
How to Appeal
- Once you receive an NOMNC, you should notify the QIO that you want to appeal. You should do this by noon the calendar day before care is set to end.
- On the day the QIO receives your request, it must immediately notify your planthat you have requested an appeal. Your plan must give you a Detailed Explanation of Non-Coverage (DENC) by the close of business that day. The DENC will explain why the services will no longer be provided and any applicable Medicare coverage rules.
- Your plan must submit evidence to the QIO regarding your appeal and you have the right to ask for a copy of that evidence.
- You can submit your own evidence in the appeal, but it is not required.
How Long Does the QIO Have to Make a Decision?
- The QIO must make its decision and notify you typically by the day the NOMNC said services would end.
What Happens Once the QIO Makes a Decision?
- If you win your appeal with the QIO (they decide in your favor), your care should continue. Before the plan decides to end services again, you should get another notice and will have the right to another QIO review.
- If you lose your appeal with the QIO (they decide against you), you will not have to pay for additional time spent in the facility because the QIO will typically decide your case the day your care is scheduled to end. If you feel that you still need care, you can continue to appeal. During your appeal, the plan cannot end your services and cannot charge you until the next review body (the Qualified Independent Contractor) makes its decision.
If you miss the deadline and still think you need more care, you can request an expedited (72-hour) appeal through your Medicare Advantage plan.
If you would like to learn more about how to appeal to Medicare Advantage plans, please click here.