If you’re receiving care in a hospital or non-hospital setting, you may be told that your Medicare will no longer pay for your care and that you will be discharged. You have the right to file a fast appeal if you feel that continued care is medically necessary. There are separate processes for hospital and non-hospital appeals. Non-hospital care includes care from a skilled nursing facility, Comprehensive Outpatient Rehabilitation Facility, hospice, or home health agency. Be aware that at each level of appeal there is a separate timeframe for when you must file the appeal and when you’ll receive a decision. Make sure to file each appeal in a timely manner or your appeal may not be considered.
Below we outline the appeals process. Throughout this process, remember that you can contact your local State Health Insurance Assistance Program (SHIP) for help. Your SHIP has trained Medicare counselors that can provide one-on-one counseling around your situation. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
First, begin the process of appealing.
If you disagree with your facility’s decision to end your care, start an appeal by contacting your Beneficiary and Family Centered Care- Quality Improvement Organization (BFCC-QIO). The notices you receive in a hospital or non-hospital setting provide information about how to appeal if you think your care is ending too soon.
If you are a hospital inpatient, you should receive a notice titledImportant Message from Medicare within two days of being admitted. This notice explains your patient rights, and you’ll be asked to sign it. If your inpatient hospital stay lasts three days or longer, you should receive another copy of the same notice up to two days, and no later than four hours, before you are discharged.
If you think you’re being discharged too soon, follow instructions on the notice to file an expedited appeal to the BFCC-QIO. Contact the BFCC-QIO by midnight of the day of your discharge. Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which explains in writing why your hospital care is ending. The BFCC-QIO should call you with its decision within 24 hours of receiving all the information it needs. If the BFCC-QIO decides your care should end, you’ll be responsible for paying for any care you receive after noon of the day after the BFCC-QIO makes its decision.
If your non-hospital care is ending, you should receive a notice titled Notice of Medicare Non-Coverage no later than two days before your care is set to end. If you receive home health care, you should receive the notice on your second-to-last care visit. This notice tells you when your care is ending and explains how to appeal.
If you think your care is ending too soon, file an expedited appeal with the BFCC-QIO by noon of the day before your care is set to end. Once you file the appeal, your provider should give you a Detailed Explanation of Non-Coverage, which explains in writing why your care is ending. The BFCC-QIO should make a decision no later than two days after your care was set to end. If the BFCC-QIO decides your care should end, you’ll be responsible for paying for any care you receive after the end date on the Notice of Medicare Non-Coverage.
Understand your right to continue appealing.>
If your appeal to the BFCC-QIO is successful, your care will continue to be covered. If your appeal is denied at this first level, you can continue to appeal by following instructions on the denial notices you receive. There are five levels of appeal in total, and you have the right to continue appealing if you’re not successful. Be aware that at each level there is a separate timeframe for when you must file the appeal and when you’ll receive a decision. Make sure to file each appeal in a timely manner. If you’re unable to appeal, a family member or other representative can appeal for you.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.)Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
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