Rehab Discharge Too Soon? Your Rehab Discharge Appeal Starts With the 2-Day Notice

The noon deadline is easy to miss, especially when your family has only just learned that Medicare coverage is ending.

Medicare instructs beneficiaries to follow the directions on the Notice of Medicare Non-Coverage “no later than noon the day before the termination date listed on the notice.”

Suppose the notice lists Friday as the coverage termination date. Your appeal request must reach the reviewer by noon Thursday. With only two days’ warning, that could mean making the call on the same day the notice arrives.

Don’t wait until the final morning if you can act sooner. Use the contact information on the notice and record when you submitted the request.

If noon has already passed, contact the BFCC-QIO or Medicare promptly to ask which review options remain available. The procedures and financial protections may differ from those for an appeal requested on time.

What Happens to the Bill

There’s a distinction families sometimes miss. Ending Medicare coverage doesn’t necessarily mean your parent must leave the facility that day. It means Medicare payment for the covered services is scheduled to stop.

Whether your parent can remain at the facility depends on the circumstances, available payment arrangements and applicable discharge protections. Ending Medicare payment and requiring a resident to leave are not always the same decision.

If the reviewer agrees that coverage should end, your parent generally won’t be responsible for the cost of services provided before the termination date on the notice, apart from any applicable Medicare cost-sharing. If your parent continues receiving services afterward, they may have to pay for those services.

Before arranging extra days at the facility, ask for its daily private-pay rate in writing. You can also review ways to pay for nursing home or rehabilitation care if Medicare no longer covers the stay.

The facility doesn’t make the final decision on a fast Medicare appeal. Medicare explains that “an independent reviewer, called a Beneficiary and Family Centered Care-Quality Improvement Organization,” or BFCC-QIO, determines whether covered services should continue.

The notice includes contact information for your state’s BFCC-QIO. You don’t need to identify the contractor yourself before calling.

After receiving the appeal, the reviewer notifies the facility and asks why your parent believes coverage should continue. It also examines the medical records. The facility must provide a Detailed Explanation of Non-Coverage, and your parent can request copies of the materials sent to the reviewer.

Making Your Case

Focus on the skilled services your parent still needs. CMS explains that Medicare coverage depends on the need for skilled care rather than the potential for improvement. Under Medicare’s rules, a lack of improvement alone isn’t a valid reason to deny otherwise qualifying skilled care coverage.

Ask the doctor or therapist which skilled services remain necessary and whether those needs can be documented in writing. Specific examples are more useful than general statements that your parent isn’t ready to leave.

Explain specific limitations, such as needing two people to help your parent stand, and ask the care team to document whether those limitations still require skilled nursing or therapy services.

Have the notice and your parent’s Medicare card available when you contact the reviewer. If you’re acting on your parent’s behalf, ask what authorization or other information the BFCC-QIO needs from you.

According to Medicare, the reviewer generally makes a decision by the close of business the day after receiving the information needed for review. If your parent’s appeal succeeds, Medicare coverage for qualifying services may continue, subject to any applicable deductibles or coinsurance.

A Medicare fast appeal addresses whether coverage should continue. If the discharge plan itself seems unsafe or improper, California’s Long-Term Care Ombudsman Program can help.

California has a separate resource for residents of long-term care facilities. The state’s Long-Term Care Ombudsman Program provides a “Statewide Ombudsman Hotline number 1-800-231-4024.” Facilities must post the number, and the hotline accepts calls 24 hours a day, seven days a week.

Ombudsman representatives assist residents of facilities such as nursing homes with concerns about their care and rights. According to the California Department of Aging, those concerns include “Improper transfer or discharge of a resident.”

The state also explains that “All Ombudsman services are provided for free and all complaints are confidential.”

For help understanding Medicare coverage and appeals, California’s Health Insurance Counseling and Advocacy Program (HICAP) offers “free, confidential one-on-one counseling.” Families in Los Angeles and Orange County can reach HICAP at 1-800-434-0222.

Remember the distinction. Contact the BFCC-QIO to appeal Medicare’s coverage decision, HICAP for Medicare counseling and the ombudsman when a long-term care facility’s transfer or discharge appears improper.

• Medicare. “Fast appeals.” Medicare.gov.
• Centers for Medicare & Medicaid Services. “Notice of Medicare Non-Coverage (NOMNC) Form Instructions.” CMS.gov.
• Centers for Medicare & Medicaid Services. “Expedited Determinations for Provider Service Terminations (Transmittal 2711).” CMS Manual System, Medicare Claims Processing Manual, Chapter 30.
• Centers for Medicare & Medicaid Services. “FFS & MA NOMNC/DENC.” CMS Beneficiary Notices Initiative.
• Centers for Medicare & Medicaid Services. “Jimmo Settlement.” CMS.gov.
• California Department of Aging. “Long-Term Care Ombudsman (Consumer).” California Department of Aging.
• California Department of Aging. “Medicare Counseling (HICAP).” California Department of Aging.

Disclaimer: This article provides general educational information about Medicare fast appeals, skilled nursing facility discharge procedures and resident rights when rehabilitation services are scheduled to end. It is not medical or legal advice and does not determine whether a particular discharge is safe or appropriate. Notice requirements, appeal deadlines and review procedures may vary depending on the circumstances and applicable Medicare program. For Original Medicare, expedited appeals generally must be requested by noon the day before the service termination date listed on the Notice of Medicare Non-Coverage. Families should follow the instructions on their notice and contact the designated Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) promptly. Concerns about an improper facility discharge may also be addressed through California’s Long-Term Care Ombudsman Program. Raya’s Paradise provides residential assisted living and supportive care services, not skilled nursing rehabilitation or hospital-level medical treatment.