December 2020: Medicare Appeals for Care that is Ending

If you are receiving care in a hospital or non-hospital setting and are told that your Medicare will no longer pay for your care (meaning that you will be discharged), you have the right to a fast appeal if you feel that continued care is medically necessary. Non-hospital care includes care from a skilled nursing facility (SNF), Comprehensive Outpatient Rehabilitation Facility (CORF), hospice, or home health agency. There are separate processes for hospital and non-hospital appeals. You can appeal by following the instructions on the notices you receive.

Hospital Discharge Appeal

  • Important Message from Medicare: Your provider should give you this notice within two days of entering the hospital as an inpatient. This notice includes instructions for how to appeal.
  • Quality Improvement Organization (QIO): To file an expedited appeal, call the QIO by midnight of the day of your discharge.
  • Detailed Notice of Discharge: Once you contact the QIO, the hospital must send you this notice. It explains in writing why your hospital care is ending.
  • The QIO should call you with its decision within 24 hours of receiving all the information it needs.

Non-Hospital (SNF/HHA/CORF/Hospice) Discharge Appeal

  • Notice of Medicare NonCoverage: You should receive this no later than two days before your care is set to end. If you receive home health care, you should receive this notice on your second to-last care visit. This notice tells you when your care is ending and explains how to appeal.
  • Quality Improvement Organization (QIO): File an expedited appeal by noon of the day before your care is set to end.
  • Detailed Explanation of NonCoverage: Once you contact the QIO, your provider should give you this notice. It explains in writing why your care is ending.
  • If you have Original Medicare, the QIO should make a decision no later than two days after your care was set to end. If you have a Medicare Advantage Plan, the QIO should make a decision no later than the day your care is to end.

If the QIO appeal is successful, your care will continue to be covered, including for the time you were appealing. If the QIO decides that your care should end, you can file a second appeal within the timeframe on your QIO denial notice. There are five levels of appeal in total. The timing and agency involved depends on which type of care is ending and whether you have Original Medicare or a Medicare Advantage Plan.

Tips for filing Medicare appeals for care that is ending

  • Follow instructions on the notices you receive and adhere to important deadlines.
  • Keep original copies of information.
  • Take thorough notes while appealing.
  • Request a letter from your doctor or health care provider in support of your continued care to strengthen your appeal.