Appealing a reduction in skilled nursing facility or home health care

Original Medicare appeals

You have rights if your skilled nursing facility (SNF) or home health agency (HHA) decides to reduce your care because it believes Medicare will no longer cover it. Be aware that the process is slightly different depending on whether you have Original Medicare or a Medicare Advantage Plan. Also note that there is a separate process if you are appealing because your care is ending.

Original Medicare

If you have Original Medicare, and your SNF or HHA decides to reduce services prescribed by your doctor because it believes that Medicare will no longer cover these services, it should give you a notice explaining why services are being reduced. If you are in a SNF, you should receive a notice indicating that Medicare may deny part of your care. This notice is often called a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). If you are receiving care from an HHA, you should receive a Home Health Advance Beneficiary Notice (HHABN). Each notice will ask you to choose one of the following three options:

  • Request care and ask the SNF or HHA to bill Medicare (demand bill). If Medicare denies coverage, you have the right to file an appeal. If your appeal is unsuccessful, you may be responsible for the cost of care. A SNF or HHA may refuse to demand bill.
  • Request care but agree to pay for the care out of pocket.
  • Turn down care. You can look for another SNF or HHA that might cover the needed care.

Remember, you have the right to a demand bill if your care is being reduced because your SNF or HHA doesn’t believe Medicare will cover it. Be aware that demand billing rules are slightly different, depending on kind of care you are receiving. If you ask a SNF to demand bill Medicare, you cannot be billed until Medicare makes a coverage decision. However, if you ask an HHA to demand bill Medicare, the HHA can bill you for home health services while Medicare makes its decision.

If you are receiving home health care, there are situations when you may receive an HHABN but do not have the right to request a demand bill. For example, if:

  • Your doctor reduces the amount of care in your plan of care. In this case, you will need to get your doctor to change their mind, get another doctor to certify that you need to continue getting the same amount of services, or go without these services.
  • The HHA reduces your care for staffing reasons, or they do not think it is safe for you to stay at home. You will need to find another HHA to get home health care, investigate other care options in your community, or go without these services.

Medicare Advantage

If you are in a Medicare Advantage Plan and your SNF or HHA is reducing your home health services because it believes that Medicare will no longer cover these services, you typically have to appeal to ask your plan for a fast (expedited) review of this decision.