Medicare Advantage (MA) enrollment continues to grow, with more than half of all Medicare beneficiaries now receiving their coverage through an MA plan. But as enrollment has increased, so have concerns regarding coverage determinations in skilled nursing facilities (SNFs). Across the country, providers, residents, and families are increasingly encountering situations in which an MA plan determines that skilled nursing or rehabilitation services are no longer medically necessary, even though the resident, family, and interdisciplinary team believe continued skilled care is warranted. This article reviews recent data regarding MA plan coverage denials and appeals, explains residents’ rights when coverage is terminated, discusses the role of the SNF staff in resident advocacy, and offers practical strategies to help residents and families understand and exercise their appeal rights.
For SNF staff, these eligibility situations present a delicate balancing act. Facilities must comply with regulatory requirements, communicate coverage decisions accurately, and avoid directing residents’ healthcare choices. At the same time, staff are obligated to support residents’ rights and ensure that they understand their options when coverage is ending. Effective advocacy does not mean encouraging every resident to file an appeal. Rather, it means assuring that residents and families understand the appeal process, have access to accurate information, and can make informed decisions based on the resident’s clinical circumstances.
What the Data Reveal About MA Coverage Denials
Recent reports have intensified scrutiny of MA plan coverage decisions involving skilled nursing care. Although an Office of Inspector General (OIG) report focused specifically on prior authorization denials for admission to SNFs rather than coverage terminations after admission, its findings have raised broader concerns regarding the accuracy of MA plan coverage determinations. The report, “Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials,” found that approximately 95% of appealed admission decision denials were ultimately overturned in favor of the resident. It concludes that the “extremely high overturn rate indicates that some enrollees were initially denied medically necessary care and raises concerns about denials that were not appealed” (Department of Health and Human Services Office of Inspector General [DHS OIG], 2026). Equally notable was the finding that only a small percentage of denied beneficiaries pursued an appeal. Many residents evidently never receive services that could have been approved simply because they were unaware of their rights or did not understand the appeals process.
Acentra Health, one of two U.S. Beneficiary and Family-Centered Care-Quality Improvement Organizations (BFCC-QIOs), identified similar concerns in its review of MA plan appeals involving SNF services. Its focused review noted disproportionate MA plan SNF appeals and raised questions about whether some Notices of Medicare Non-Coverage (NOMNCs) were being issued prematurely or inappropriately, without sufficient consideration of the resident’s clinical needs and recovery status. Acentra Health (2026a) also identified concerns regarding repeated NOMNCs and the potential use of generalized timelines or nonclinical factors rather than individualized review of the resident’s current condition. These findings do not suggest that all MA plan denials are inappropriate. But they do reinforce an important reality. A coverage determination is not necessarily the final word. Residents have the right to request an expedited review when they believe a coverage decision does not accurately reflect their clinical needs, current skilled services, or risk for decline if services are discontinued. Reprinted questions and answers from its webinar about MA plan appeals is also a useful resource (Acentra Health, 2026b).
Understanding Medicare Coverage Requirements
Discussing coverage determinations with residents and families begins with an understanding of Medicare’s coverage criteria. As outlined in the 2024 Medicare Advantage and Part D final rule, MA plans are required to follow Medicare coverage requirements. See the AAPACN article “Seven Ways NACs Can Be Proactive With New Medicare Advantage Plan Rules” for more information. Coverage decisions should be based on the resident’s current clinical condition and need for daily skilled nursing or rehabilitation services, rather than on a diagnosis alone or an expectation of full recovery. Medicare coverage may continue when a resident requires daily skilled services that are medically necessary and sufficiently complex to require the knowledge, assessment, and intervention of licensed nursing staff or qualified therapists. A common misconception is that Medicare coverage ends once a resident stops improving. In reality, coverage does not depend on the resident’s potential for improvement. Skilled services may remain covered when needed to maintain the resident’s current level of function or to prevent or slow further decline. The key consideration is whether the resident continues to require skilled observation, assessment, management, or treatment that can only be provided safely and effectively by qualified healthcare professionals in the SNF setting. For SNFs, this evaluation underscores the importance of accurate and comprehensive documentation. The medical record should clearly reflect the resident’s current condition, skilled needs, clinical complexity, response to treatment, and risks associated with discontinuing skilled services. Coverage determinations should be individualized and based on the resident’s unique circumstances, rather than applying generalized benchmarks or expected lengths of stay. Understanding Medicare coverage requirements is essential because those same coverage principles often become the focus of a resident’s appeal when an MA plan determines coverage should end. For additional information, see chapter 8 of the Medicare Benefit Policy Manual in the Internet-Only Manuals from the Centers for Medicare & Medicaid Services (CMS).
Understanding the Resident’s Appeal Rights
When an MA plan determines that Medicare-covered skilled services should end, residents must receive the NOMNC form, delivered at least two calendar days before the end date (CMS, 2025). Although the MA plan issues the notice, many plans require SNF staff to deliver it to the resident. The NOMNC serves a critical purpose. It informs the resident that coverage is expected to end and explains the resident’s right to request an expedited review by the BFCC-QIO. The notice also explains how to initiate that review and the required time frame. The expedited determination process protects beneficiaries from interruptions in medically necessary care while the reviewer evaluates whether coverage should continue. If the resident requests a timely appeal, the BFCC-QIO conducts an immediate review of the case. For more information, see the AAPACN articles Medicare Expedited Determination vs. Financial Liability Notices: What’s the Difference? and Expedited Determination Notices: Keys to Avoiding Financial Liability, Survey Issues. However, many residents may not fully understand the implications of the NOMNC. Some may interpret it as an eviction notice. Others assume the health plan’s decision cannot be challenged. Still others become so overwhelmed by the process that they choose not to appeal, even when they disagree with the determination. At this juncture, facility staff can play an essential role.
The Facility’s Role in Resident Advocacy
Residents frequently seek guidance from facility staff because they trust the care team and may not understand the terminology in Medicare notices. Taking time to answer questions, explaining the role of the BFCC-QIO, and reviewing available options can help residents exercise their rights with confidence. It will also reduce confusion and lessen anxiety during a challenging transition. For many residents and families, the receipt of a NOMNC is their first indication that Medicare coverage may be ending. Rather than simply presenting the notice for signature, facilities can engage residents and families in a meaningful discussion about the resident’s care needs, progress, goals, and discharge readiness. These conversations should focus on helping residents understand why the coverage determination was made, what skilled services they are currently receiving, what progress has been achieved, and what may be at risk if services are discontinued. Reviewing this information allows residents and families to evaluate how the Medicare coverage criteria apply to the resident’s individual circumstances and whether they should request an expedited review. These discussions can also uncover information not fully reflected in the medical record. Family members may raise concerns regarding mobility, safety, cognition, caregiver availability, or the resident’s ability to function in the discharge environment. Such observations may warrant additional interdisciplinary review and can provide valuable context when evaluating the resident’s ongoing skilled care needs.
Practical Examples: How to Approach Residents and Families
Example 1: Resident Receiving Therapy After a Stroke
Situation: An MA plan issues a NOMNC indicating therapy coverage will end in two days. The therapy team believes the resident continues to make measurable gains in transfers and ambulation.
Facility Approach:
“Mrs. Jones, we are providing you with this Notice of Medicare Non-Coverage because your Medicare Advantage plan has determined that coverage for your skilled nursing stay will end on Friday. This decision was made by your health plan, not the facility.
The notice explains your right to request an immediate review by an independent Quality Improvement Organization if you disagree with the plan’s decision. If you request the review by the deadline listed on the notice, the QIO will evaluate whether your Medicare-covered services should continue.
Our therapy team believes you are making progress with transfers and ambulation. We want to ensure you understand your rights and options. If you request an expedited review by the deadline listed, the QIO will generally issue a decision before all services will end this Friday. We can review the notice with you, answer questions about the coverage determination and appeal timelines, and ensure you understand your options.”
Example 2: Family Reports Ongoing Functional Decline
Situation: Documentation indicates the resident has met therapy goals, but the daughter reports significant safety concerns during weekend visits.
Facility Approach:
“Thank you for sharing your observations. We want to ensure we have the most accurate and complete picture of your father’s current abilities and safety needs. We will communicate your concerns to the therapy and nursing teams and determine whether additional assessment or documentation is warranted.
Your father’s Medicare Advantage plan has determined that coverage will end on the date listed in the notice. If you disagree with that decision, you have a right to request an immediate review by a Quality Improvement Organization. We are happy to answer questions and make sure you have the information you need to make an informed choice.”
Example 3: Repeat NOMNC Following a Previous Successful Appeal
Situation: An MA plan issues a second NOMNC shortly after a prior appeal resulted in continued coverage.
Facility Approach:
“Because you successfully appealed a previous coverage termination, it is important to understand what clinical changes the plan believes have occurred since that decision. We can review the notice with you and discuss whether you would like to request another expedited review.”
This conversation is particularly relevant, given CMS guidance requiring MA plans to explain the specific change in condition that supports a repeat termination decision following a favorable appeal. For more information, see the AAPACN on-demand webinar SNF ABN, NOMNC, DENC – What Has Changed for This Alphabet Soup of Notices?
Documentation: The Foundation of Effective Advocacy
Regardless of whether a resident opts to appeal, accurate documentation remains one of the facility’s strongest advocacy tools. The medical record should clearly demonstrate why skilled nursing or rehabilitation services continue to be medically necessary and how those services relate to the resident’s current condition, goals of care, and functional abilities. Documentation should tell the resident’s story by describing the clinical complexity of the resident’s condition, the skilled services being provided, the resident’s response to treatment, and the ongoing assessment, monitoring, or intervention required from licensed nursing staff or qualified therapists. Records should also reflect changes in condition, progress toward goals, barriers to discharge, and any risks associated with discontinuing skilled services prematurely. Because the reviewers rely heavily on the medical record when evaluating coverage decisions, incomplete or nonspecific documentation may make it difficult to fully understand the resident’s ongoing need for skilled care. Conversely, documentation that clearly explains the resident’s functional limitations, skilled needs, and clinical risks provides a more complete picture of why continued skilled care may be necessary. Facilities should ensure that documentation supports the need for daily skilled services and shows why those services require the knowledge, judgment, and skills of licensed nurses or therapists. Documentation must also reflect the resident’s progress toward established goals or, when improvement is not expected, the need for skilled services to maintain function or prevent or slow further decline. Strong documentation not only supports appeals but can also help promote more accurate coverage determinations from the outset.
Conclusion
As MA plan enrollment continues to expand, SNFs will likely encounter increasing numbers of coverage determinations and resident questions regarding appeals. Recent findings from the OIG, CMS policy changes, and increasing scrutiny of MA plan coverage determinations underscore the importance of ensuring residents understand the protections available to them. Facilities play a critical role in this process. Through clear communication, strong documentation, family engagement, and resident education, SNFs can help residents navigate complex coverage decisions without directing their choices. Perhaps most importantly, facilities can ensure residents understand that a NOMNC is not necessarily the end of the conversation. Residents have the right to ask questions, seek clarification, and request an expedited review when they believe continued skilled care remains medically necessary.
AAPACN Resources
RAC-CTA – Beneficiary Notices in a SNF for the Advanced Medicare Specialist
Medicare Basic Training Part 9: Beneficiary Notices Initiative On-Demand Workshop
Other Resources
Acentra Health. (2026a). Medicare advantage plan appeals in skilled nursing facilities: a data-driven review of coverage decisions and clinical implications. https://acentraqio.com/wp-content/uploads/2026/01/SNF_Focus_Study_Webinar_508-1.pdf
Acentra Health. (2026b). Q&A from Acentra webinar on managed care denial overturns. https://acentraqio.com/webinar/maplanappealsinsnfqa/
Centers for Medicare & Medicaid Services. (2025). FFS & MA NOMNC/DENC. https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-nomnc-denc
Department of Health and Human Services Office of Inspector General (DHS OIG). (2026). Medicare advantage organizations overturned nearly all appealed prior authorization denials for skilled nursing facility admission, raising concerns about initial denials. https://oig.hhs.gov/documents/audit/11694/OEI-09-24-00331.pdf
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