Medicare denies or terminates skilled nursing facility coverage more often than most families realize. The good news: you have a right to appeal — and many appeals succeed. Acting quickly is essential; some deadlines are as short as 2 days.
Why Medicare SNF Coverage Gets Denied
- Medicare determines the patient no longer needs “skilled care” (the most common reason)
- The facility’s documentation doesn’t adequately support continued skilled care need
- Coverage ends at day 100 (maximum benefit period)
- The patient didn’t have a qualifying 3-day inpatient hospital stay
- The care needed is considered “custodial” rather than skilled
Step 1: Get the Required Notice
Before Medicare coverage ends, the nursing home must provide you with a Notice of Medicare Non-Coverage (NOMNC) — a written notice explaining why coverage is ending and your appeal rights. You must receive this notice at least 2 days before coverage ends.
If you never received this notice and Medicare was denied, the nursing home may have violated your rights. Contact the Missouri Long-Term Care Ombudsman at (800) 309-3282.
Step 2: File a Fast Appeal (Most Important)
Contact your state’s Quality Improvement Organization (QIO) — in Missouri, this is Primaris. File your appeal no later than noon of the day your coverage is scheduled to end.
- Missouri QIO (Primaris): 1-800-735-6776
- The QIO must issue a decision within 1 business day of receiving all relevant information
- Critical: You will NOT be billed for care received during the QIO review period
If the QIO Upholds the Denial: Further Appeals
- Level 2 — Reconsideration: Request review by a Qualified Independent Contractor (QIC) within 180 days. Decision within 60 days.
- Level 3 — ALJ Hearing: Administrative Law Judge hearing if the amount in dispute exceeds $180 (2025). Request within 60 days of QIC decision.
- Level 4 — Medicare Appeals Council (MAC): Review by the Departmental Appeals Board
- Level 5 — Federal District Court: For claims over $1,840 (2025)
Tips for a Successful Appeal
- Ask the facility for supporting documentation — nursing notes, therapy notes, and physician orders that document the skilled care need
- Get a statement from the treating physician explaining why skilled care is still medically necessary
- Reference the Jimmo v. Sebelius settlement — Medicare cannot deny coverage solely because a patient isn’t improving
- Contact your State Health Insurance Assistance Program (SHIP) — Missouri SHIP at (800) 390-3330 provides free counseling for Medicare beneficiaries
