Medicare Denied Skilled Nursing Facility Stay

What This Means

If the facility handed you a Notice of Medicare Non-Coverage (NOMNC) before your already covered skilled nursing facility (SNF) care ends, request a fast appeal from the independent reviewer listed on that notice. Under Original Medicare, ask the BFCC-QIO by noon of the calendar day after you receive the notice (42 CFR 405.1202(b)(1)). Under Medicare Advantage, ask the Medicare-contracted independent reviewer by noon of the first day after delivery (42 CFR 422.626(a)(1)); the fast-appeal request goes to that reviewer, not your plan. Follow your notice’s instructions immediately. Medicare.gov describes the usual notice deadline as noon the day before the listed coverage end date, but late notice delivery can make that date differ from the receipt-based rule. If the dates appear inconsistent, call the reviewer at once rather than waiting.

Did the facility end already covered SNF care as no longer medically necessary or as custodial without a valid NOMNC? Ask the reviewer to check notice validity. If the reviewer determines the notice was invalid, coverage continues until at least 2 days after you receive valid notice, unless continuing it would threaten your health or safety (42 CFR 405.1202; 422.626 for Medicare Advantage). Raise that with the facility and the reviewer rather than assuming only the slower standard appeal is left to you. Running out of benefit days is different: a NOMNC is not required solely because your covered days are exhausted (Medicare SNF booklet, Section 5).

If there was never a covered stay to end — most often because the 3-day inpatient hospital stay requirement was not met — the fast-appeal deadline does not apply and the standard deadlines govern: 120 days from the date you receive your Medicare Summary Notice for Original Medicare — receipt is presumed 5 days after the date printed on it, and the MSN states your exact deadline — or 65 days from the date on your denial notice for Medicare Advantage (appeals). If a Medicare Advantage plan denied urgently needed SNF admission or care before coverage began, ask the plan for an expedited reconsideration when waiting for a standard decision could seriously jeopardize your life, health or ability to regain maximum function (42 CFR 422.584). Follow the plan denial notice; this is a different route from the independent reviewer for a NOMNC appeal.

Not sure this is your situation? Broad searches often land here when a neighboring guide is the better fit:

• Was your hospital stay classified as observation instead of inpatient? Start with observation vs. inpatient — observation days do not count toward the 3-day inpatient rule.
• Is a hospital, not a nursing facility, telling you to leave too soon? See Medicare is discharging you too soon.
• Did coverage end because you used all 100 covered days? See benefit limit reached.

SNF denials can be very costly. Without Medicare coverage, you could be responsible for the facility’s full daily rate, which can run several hundred dollars per day and varies widely by location and level of care.

Why This Happens

• You did not meet the usual 3-day inpatient hospital stay requirement. Original Medicare generally requires at least 3 consecutive hospital inpatient days before SNF care. Observation time does not count. Ask whether an approved ACO three-day-rule waiver applies. A Medicare Advantage plan may waive this stay requirement under 42 CFR 422.101(c)(2).
• Your hospital stay was classified as observation. If the hospital placed you on observation status instead of admitting you as an inpatient, those days do not count toward the 3-day requirement. You may not have even known you were on observation. (See our observation vs. inpatient guide for more.)
• Medicare determined your care is “custodial.” Medicare covers skilled nursing care — things like physical therapy, wound care, IV medications, or monitoring by a nurse. It does not cover custodial care, which is help with daily activities like bathing, dressing, and eating. If Medicare decides your care is custodial, it will deny coverage.
• Medicare says skilled care is no longer needed. Even if your stay was initially approved, Medicare may stop coverage if it determines you no longer need skilled care. This often happens during a continued-stay review.
• You used all available Part A SNF benefit days. Original Medicare Part A covers up to 100 SNF days per benefit period, subject to continued eligibility. Coverage can end sooner if you no longer meet the requirements, including the need for daily skilled care. Once those days are exhausted, Part A will not pay for more SNF days in that benefit period, although Part B may still cover some services.
• Your Medicare Advantage plan denied authorization. MA plans may require prior authorization and use plan networks for SNF care, but for basic benefits they must follow applicable Traditional Medicare coverage criteria (42 CFR 422.101). Ask the plan to identify the rule it used and whether it waives the three-day stay requirement.

Should You Appeal?

What To Do Next

1. Identify the notice and the reason coverage is ending. A Notice of Medicare Non-Coverage (NOMNC) explains fast-review rights when already covered care is ending because it is no longer considered covered skilled care. Exhausting benefit days is a different situation. The SNF Advance Beneficiary Notice of Non-coverage (SNFABN) addresses potential payment responsibility under Original Medicare; its choices are explained below.
2. Request a fast appeal if already covered care is ending. Call the independent reviewer listed on your NOMNC, not the Medicare Advantage plan: the BFCC-QIO for Original Medicare or the Medicare-contracted reviewer for MA. Request review by noon of the calendar day after receiving the notice under Original Medicare or noon of the first day after delivery under MA. Follow the notice’s instructions and act immediately if its date appears different from the receipt-based deadline (Medicare.gov fast appeals). A late request can still be reviewed, but the expedited timeframe and applicable financial protection may be lost.
3. Request the appeal first; gather evidence next. Do not wait for a doctor’s letter or records before calling the reviewer. After requesting fast review, ask for the Detailed Explanation of Non-Coverage (DENC) and access to the material sent to the reviewer: ask the facility under Original Medicare or your plan under Medicare Advantage. Ask your care team to explain the skilled services you need and why. The DENC explains the specific reasons for ending coverage; it is not a prerequisite for requesting review.
4. Check the hospital-stay rule and any waiver. Count consecutive inpatient calendar days starting with the admission day and excluding the discharge day; observation days do not count. Ask whether an approved ACO waiver or your Medicare Advantage plan’s waiver applies. If inpatient-to-observation reclassification caused the denial, consider appealing that status change too.
5. For a standard claim denial, follow the MSN or plan notice. Use its appeal instructions and deadline, with supporting records. If you already requested a fast appeal, follow the reviewer’s decision for any next appeal step; do not assume you must also start a separate standard appeal for that same coverage-ending decision.
6. Get free help. Contact your State Health Insurance Assistance Program (SHIP) for free counseling, or call 1-800-MEDICARE (1-800-633-4227). Medicare’s claims & appeals guide walks through the SNF appeal steps.

If You Want to Stay When Coverage Is Ending

Under Original Medicare Part A, a facility that expects Medicare to deny continued care as not medically necessary or as custodial uses the SNFABN to explain your possible costs. Its prediction is not yet Medicare’s official payment decision. Check the listed care, starting date, reason and estimated cost, and ask the facility to explain anything unclear before you choose. The facility cannot choose for you.

The official SNFABN form offers these choices:

• Option 1: Continue the listed care and have Medicare billed. Requesting an official payment decision is sometimes called a demand bill. The facility must submit the claim and tell you when it did. It cannot collect payment for these Part A services before Medicare’s official decision. If Medicare denies payment, you may owe the charges; follow the Medicare Summary Notice (MSN) to appeal. This choice does not guarantee payment.
• Option 2: Continue the listed care without billing Medicare. The facility can charge you now. Because Medicare is not asked to decide that claim, there is no Medicare payment decision to appeal for those services.
• Option 3: Decline the listed care. You are not charged for care you do not receive, and there is no payment decision to appeal for it. Part B may cover some separate services, but that does not pay for room and board.

These choices concern the specified Original Medicare Part A process. Do not assume they apply to Medicare Advantage, a Part B ABN, or a voluntary notice for exhausted benefit days or a missing qualifying hospital stay. Ask the facility or SHIP which process applies to your situation. CMS describes these distinctions in its SNFABN instructions.

A demand bill does not replace or extend the NOMNC fast-appeal deadline. If you want fast review of ending covered care, contact the reviewer on the NOMNC immediately, even while sorting out payment choices.

Does Losing Medicare Coverage Mean I Must Leave the Nursing Home?

Ending Medicare payment and transferring or discharging you from the nursing home are separate processes. If the facility says you must leave, ask for its written transfer/discharge notice, including the reason, proposed date and destination, and how to appeal. A Medicare coverage appeal does not substitute for a facility-discharge appeal.

Contact your State Long-Term Care Ombudsman promptly for help with resident rights and the discharge notice, and follow the notice’s appeal deadline. Federal rules generally require advance notice, but exceptions mean 30 days is not guaranteed. Loss of Medicare payment does not promise a free or unlimited stay: nonpayment after appropriate notice can be a lawful discharge reason. The applicable federal requirements are in 42 CFR 483.15(c).

Sources

• Medicare.gov: Skilled Nursing Facility Care — the 3-day inpatient rule, the 100-day limit, and 2026 cost-sharing ($0/day for days 1–20 after any applicable Part A deductible; $217/day for days 21–100 under Original Medicare).
• 42 CFR 409.30: Basic requirements for SNF coverage — the 3-consecutive-day qualifying inpatient stay, in regulation.
• Medicare.gov: Fast (expedited) appeals — the NOMNC-triggered independent review when already covered SNF care is ending.
• CMS: Jimmo Settlement FAQs — improvement is not required, but skilled-care need and all other coverage criteria still apply.
• CMS: SNF Advance Beneficiary Notice — Original Medicare Part A notice, official form, payment choices and instructions.
• Medicare: Coverage of Skilled Nursing Facility Care, Section 5 — coverage-ending notices, benefit exhaustion and demand billing. Use the current coverage page above for 2026 costs.
• Medicare: Nursing home care — custodial care and separately covered Part B services.
• Federal Register: Appeal Rights for Certain Changes in Patient Status (Oct 2024) — the Alexander v. Azar rule letting Original Medicare patients appeal observation status.

Frequently Asked Questions