Medicare Skilled Nursing Facility Denied: Appeal

Medicare skilled nursing facility (SNF) coverage is one of the most valuable benefits available to seniors after a hospitalization — but it comes with strict eligibility rules that are frequently misapplied, resulting in wrongful denials. If your SNF stay has been denied or is being cut short, you have immediate appeal rights.

What Medicare SNF Coverage Provides

Medicare Part A covers care in a skilled nursing facility following a qualifying hospital stay. Coverage includes:

• Days 1–20: Medicare pays 100% (after the Part A deductible)
• Days 21–100: Medicare pays all but a daily coinsurance (around $200/day in 2025)
• Days 101+: Patient is responsible for all costs

SNF care covered includes skilled nursing, physical therapy, occupational therapy, speech therapy, and related services.

The 3-Midnight Inpatient Rule

To qualify for Medicare SNF coverage, you must have had a qualifying hospital stay of at least 3 consecutive nights as a formal inpatient — not under observation status.

This is a critical distinction. If you were in the hospital for several days but designated as an "outpatient under observation," those nights do not count toward the 3-midnight qualifying stay. You could spend 4 nights in the hospital and still not qualify for SNF coverage if you were under observation status.

If this happened to you, you have the right to request a review of your observation status. See the Medicare NOTICE Act section — and appeal your inpatient status through the QIO rapid appeal process.

The Skilled Care Requirement and the Jimmo Standard

To receive SNF coverage, you must require skilled care — services that require the professional judgment of a licensed nurse or therapist. The plan or Medicare contractor may deny ongoing SNF coverage by arguing that you no longer need skilled care.

However, the Jimmo v. Sebelius settlement (2013) established that Medicare covers skilled care to maintain your condition or prevent decline — even when you are not expected to improve. If your SNF coverage is being cut because "you've reached a plateau" or "no further improvement expected," cite Jimmo explicitly in your appeal.

SNF Benefit Periods

Medicare SNF coverage is organized into benefit periods. A new benefit period begins each time you go 60 consecutive days without skilled care in a hospital or SNF. At the start of each new benefit period, a new 3-midnight qualifying hospital stay is required.

This means if you were discharged from a SNF, spent 60+ days at home without skilled care, and then need SNF care again, the clock resets — and so does the 3-midnight requirement.

Rapid Appeal When SNF Discharge Is Imminent

If your SNF is telling you that Medicare will no longer cover your stay, you have the right to an urgent appeal through the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization). The BFCC-QIOs currently operating are KEPRO and Livanta, depending on your state.

Here is what to do:

1. Receive the notice: The SNF must give you a written Notice of Medicare Non-Coverage (NOMNC) at least 2 days before Medicare coverage ends
2. Call the BFCC-QIO immediately: The phone number is on the notice
3. Request a review before the termination date: Your coverage continues while the QIO reviews the case — you will not be charged for those additional days while the review is pending
4. The QIO contacts the SNF: Reviews your medical records, typically within 2 business days
5. You receive a written decision

If the QIO sides with the SNF, you can then escalate to the standard 5-level Medicare appeal process.

The 5-Level Standard Appeal

For retroactive claim denials (after you've already left), the standard 5-level process applies:

1. Redetermination by the MAC — file within 120 days of the denial
2. Reconsideration by the QIC — file within 60 days
3. ALJ Hearing at OMHA — file within 60 days, amount in controversy required
4. Medicare Appeals Council — file within 60 days of ALJ decision
5. Federal District Court — for qualifying disputes

What to Include in a SNF Appeal

• Hospital records confirming inpatient status (not observation) for the qualifying stay
• SNF nursing notes documenting the skilled care being provided
• Physician certification of continued need for skilled care
• Citation of the Jimmo settlement if maintenance care is at issue
• A letter from the treating physician explaining why discharge would result in decline or harm

SHIP Counselors and Free Help

State Health Insurance Assistance Program (SHIP) counselors offer free guidance on SNF appeals and QIO rapid reviews. They know the local BFCC-QIO contacts and timelines. Find your SHIP at shiphelp.org or call 1-800-MEDICARE.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal