Medicare Advantage Denied Skilled Nursing Facility (SNF) Stay

Skilled nursing facility (SNF) denials are among the most disruptive and emotionally charged insurance denials Medicare Advantage members face. Being told you must leave a nursing facility — or that your stay was never covered — can upend recovery plans for some of the most vulnerable patients.

The good news: federal law gives you powerful, time-sensitive protections. Here's how to use them.

How SNF Coverage Works Under Medicare Advantage

Medicare Advantage plans must provide at least the same SNF benefits as Original Medicare. Under Original Medicare, SNF coverage requires:

1. A qualifying inpatient hospital stay: At least 3 consecutive days as an inpatient (observation stays do NOT count toward this requirement).
2. Medical necessity: The SNF stay must be for a condition treated during the qualifying hospital stay or a condition that arose during the SNF stay.
3. Skilled care requirement: The patient must need daily skilled nursing care or skilled rehabilitation services — not just custodial (personal care) assistance.
4. Up to 100 days of SNF coverage per benefit period: Days 1–20 are fully covered; days 21–100 require a daily copayment.

MA plans often add their own Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization requirements on top of these federal criteria, and may conduct ongoing utilization reviews to shorten approved stays.

The Jimmo v. Sebelius Settlement: Improvement Is NOT Required

One of the most important legal protections for SNF patients is the Jimmo v. Sebelius settlement (2013). This case established that Medicare — and by extension Medicare Advantage — cannot deny coverage solely because a patient is not expected to improve. The law covers maintenance therapy: skilled care that prevents deterioration or maintains current function.

If your MA plan denied your SNF stay because you weren't "making progress" or wouldn't "improve," that is an improper denial. Cite Jimmo v. Sebelius directly in your appeal.

Common MA SNF Denial Reasons

• No qualifying 3-day hospital stay: The patient was held under observation status (not admitted as an inpatient) before the SNF.
• Not medically necessary: The plan's utilization reviewers determined SNF-level care is no longer needed.
• Custodial care classification: The plan categorized care as custodial (not covered) rather than skilled.
• Improvement standard improperly applied: The plan denied coverage because the patient wasn't expected to improve, in violation of Jimmo.
• Prior authorization not obtained or not renewed: PA for the SNF stay was denied or not extended.

Your Immediate Rights When Facing SNF Discharge

If your MA plan or the SNF notifies you that your stay is ending (or coverage is ending while you remain), you have immediate appeal rights that must be exercised quickly.

The Important Message from Medicare

The SNF is required to give you a written notice called the "Important Message from Medicare About Your Rights" when your stay is ending. This notice must explain your right to an expedited review. Read it carefully.

Request an Immediate BFCC-QIO Review

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) are CMS-contracted organizations that handle immediate discharge appeals for Medicare beneficiaries, including those in MA plans.

If you believe your SNF discharge is premature, call your BFCC-QIO immediately — before you leave the facility. You must request this review by noon of the day before your planned discharge.

• Livanta covers most states. Call 1-888-524-9900 or visit livantaqio.com.
• KEPRO covers a smaller group of states. Call 1-800-633-4227 to find out which QIO serves your state.

When you request a QIO review, you are entitled to remain in the SNF at no additional cost beyond your normal copayment until the QIO issues its decision. The SNF cannot discharge you while the review is pending.

Filing a Formal Level 1 Appeal with Your MA Plan

If the QIO upholds the discharge or if your SNF denial was a pre-authorization denial (not a mid-stay discharge), file a Level 1 appeal with your MA plan. Include:

• The denial notice or discharge notice
• A letter from your physician explaining why continued SNF care is medically necessary
• Clinical documentation of your diagnosis, treatment needs, and functional status
• A statement citing Jimmo v. Sebelius if the plan applied an improvement standard
• Documentation of the qualifying 3-day hospital stay if that was disputed

The plan must decide an expedited appeal within 72 hours.

Level 2 External Independent Review: Complete Guide" class="auto-link">External Review Through MAXIMUS

If your MA plan upholds the denial at Level 1, escalate to MAXIMUS Federal Services for an independent external review. MAXIMUS applies Original Medicare coverage standards — which cannot include an improvement standard.

Tips for Winning Your SNF Appeal

• Never leave the facility before requesting QIO review if you believe the discharge is premature. Once you leave, you lose the protection against discharge during review.
• Get your doctor's support in writing immediately. A detailed letter from the attending physician carries significant weight.
• Cite Jimmo v. Sebelius explicitly if improvement was a factor in the denial.
• Keep records of all communications — dates, names, what was said.
• Contact SHIP for free help navigating your appeal.

Fight Back With ClaimBack

SNF denials have timelines that move fast. ClaimBack helps you act immediately, build your appeal correctly, and access the federal protections you're entitled to as a Medicare Advantage member.

Start your free appeal →

Related Reading

• What Is Medical Necessity?
• Internal vs. External Insurance Appeal
• Common Reasons Insurance Claims Are Denied