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.

Were you already receiving Medicare-covered SNF care that stopped without a valid NOMNC — for example, a mid-stay reclassification of your care as custodial? Then coverage must continue 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.

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). The sections below cover each denial reason and the appeal path that fits it.

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 exceeded the 100-day benefit limit. Medicare covers up to 100 days of SNF care per benefit period. After day 100, there is no more Medicare coverage regardless of medical need.
• 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. Get the written notice. Before your covered care ends, the facility must give you a Notice of Medicare Non-Coverage (NOMNC) — this is the notice that starts your fast-appeal clock and explains your rights. (A different notice, the SNFABN, is used when Medicare may not cover care because it is custodial or not medically necessary.)
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. Get documentation from your care team. Ask your doctor, nurses, and therapists for notes explaining why you still need skilled care. If they support continued coverage, their documentation is your strongest evidence.
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. File a formal appeal. Follow the instructions on your denial notice to file within the deadline. Include your doctor’s supporting statement and any relevant medical records.
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.

Sources

• Medicare.gov: Skilled Nursing Facility Care — the 3-day inpatient rule, the 100-day limit, and 2026 cost-sharing ($0 for days 1–20; $217/day for days 21–100).
• 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 — Medicare covers skilled maintenance care regardless of improvement potential.
• Federal Register: Appeal Rights for Certain Changes in Patient Status (Oct 2024) — the Alexander v. Azar rule letting Original Medicare patients appeal observation status.
• HHS OIG: Medicare Advantage Appeal Outcomes (OEI-09-16-00410) — MA plans overturned 75% of their own denials on appeal (2014–2016); only about 1% of denials were appealed.

Frequently Asked Questions