Care is ending

What it means

Medicare or your plan is stopping payment for care you are getting now. Medicare calls it a discharge or a termination of services. For a private plan, cutting short care it already approved is a denial, even if the letter does not say so.

Who has to act first

You do, and the clock may be hours long. Check the date and time on your notice, which controls.

Original Medicare, hospital discharge. The hospital must give you the Important Message from Medicare (Form CMS-10065, named for the Centers for Medicare & Medicaid Services) within 2 calendar days of admission. Ask the Quality Improvement Organization (QIO), the independent reviewer, for a fast appeal by phone or in writing no later than the day you are discharged. The QIO decides within 1 calendar day of getting the information it asks for, and the hospital carries the burden of proof. With a timely request you are not responsible for the stay, beyond normal coinsurance and deductible, until noon of the day after you are told the decision.

Skilled nursing facility, home health, outpatient rehabilitation facility or hospice. The provider must give the Notice of Medicare Non-Coverage (Form CMS-10123) at least 2 days before services end. Ask the QIO by noon of the calendar day after you receive it. The QIO decides within 72 hours. For services not given in a facility, such as home health, a physician must certify that ending them may put your health at significant risk. A reduction in services is not a termination for this purpose.

Medicare Advantage. A hospital discharge works the same way. For skilled nursing, home health or outpatient rehabilitation facility services, ask the QIO by noon of the day after you get the notice. The decision is due by close of business the day after the reviewer has the information, and the plan carries the burden of proof.

Late. A late request is still decided, but without the fast deadline or the protection from charges. After leaving a hospital you have 30 calendar days to ask.

Private plans. An approved course of care cannot be cut short without enough notice for you to appeal and get a decision first. Non-grandfathered plans must keep covering it while you appeal on those terms. An urgent request to extend care is decided within 24 hours if you make it at least 24 hours before the approved care ends. The plan must decide an urgent appeal within 72 hours.

Arguments that work

• Improvement is not the test. Medicare coverage of skilled care does not depend on whether you are improving. It covers care to maintain your condition or slow decline.
• The burden is on them. In a fast Medicare appeal the hospital, provider or plan must prove that ending care is right.
• A defective notice. If the notice for a skilled nursing facility or home health service is not valid, the provider is liable for continued services until 2 days after a valid one.
• Safety. Your doctor can state why stopping is unsafe and what the discharge plan lacks.
• Private plans. An approved course cut short without time to appeal first breaks the notice rule.

Evidence to gather

• The notice, with the date and time you received it (you).
• Doctor and therapy notes showing ongoing skilled needs (your doctor, the facility).
• The discharge plan and what is missing, such as caregivers or equipment (the facility).
• For private plans, the original approval showing dates (the plan).

What to send

Use the line for your coverage. Where it says call, call first and put it in writing afterwards.

• Medicare (Original Medicare or a Medicare Advantage plan). Call the Quality Improvement Organization named on your notice first. If you cannot find the number, call 1-800-MEDICARE (1-800-633-4227). The fast review is asked of that reviewer, so a letter to your plan is not the request. Use the phone script for a fast Medicare appeal, and read the fast appeals guide for a worked date example. The private-plan expedited letter below is not written for Medicare.
• Medicaid health plan (managed care). Call the plan and say you want to appeal and keep your services going while you appeal. Ask within 10 calendar days of the date the plan sent the notice, or before the cut takes effect if that is later. Your provider cannot ask for this for you. Use the phone script for a Medicaid plan appeal, then send the letter to appeal and keep services going.
• Job-based or Marketplace plan, not Medicare Advantage. Send an expedited appeal with a doctor’s urgency statement, and ask for expedited external review at the same time if waiting could seriously harm your health. The letter about ongoing treatment and the expedited external review letter are written for these plans.