Why Appeals Matter: Protecting Medicare Advantage Residents in Skilled Nursing Facilities

Recent national reporting and regulatory guidance reveal a troubling and consistent pattern in how Medicare Advantage (MA) plans deny and terminate skilled nursing facility (SNF) coverage. The evidence is clear: appeals work—and SNFs play a vital role in ensuring residents access them.

Repeated Denials Are Widespread—and Often Overturned
New research from one of two of the Nation’s Quality Improvement Organizations (QIOs) shows that 93% of all SNF coverage appeals come from MA members, even though MA represents only about half of Medicare enrollment. Alarmingly, QIO physicians disagreed with MA plan denials half the time, and in 77% of cases involving repeated termination notices.

In many cases, MA plans issued multiple Notices of Medicare Non-Coverage (NOMNCs) during the same stay—sometimes weekly and sometimes without any change in the resident’s clinical condition.

CMS Confirms: Plans Must Justify Repeated Terminations
As of January 1, 2025, CMS requires MA plans to explain what has changed before reissuing a termination notice after an appeal is overturned. That explanation must be included in the Detailed Explanation of Non-Coverage (DENC).

Despite this requirement, advocates continue to report MA plans issuing back-to-back termination notices even after successful appeals—placing residents and facilities in an exhausting and disruptive cycle.

Legal Scrutiny Highlights Systemic Concerns
A federal court recently allowed a class action lawsuit against Humana to move forward over allegations that AI tools were used to deny post-acute care without meaningful clinician review. The court recognized that repeated denials could cause irreparable harm, forcing beneficiaries to either leave care prematurely or remain in facilities at financial risk while appeals are pending.

Notably, the court acknowledged that MA plans frequently overturn denials during appeals—only to issue new denials shortly thereafter—underscoring why residents must be encouraged to keep appealing.

Why SNFs Must Encourage Appeals
Appeals are not just a resident right—they are a critical safeguard:

• Many MA denials are overturned, even after multiple attempts.
• Residents are often far from meeting mobility and functional goals or continue to have a skilled nursing need when coverage is terminated.
• Appeals help ensure decisions are based on individual clinical need, not automated timelines or cost-driven algorithms.
• Encouraging appeals supports patient safety, continuity of care, and regulatory compliance.
• Positive appeal outcomes ensure MA plans are the primary payor source while skilled therapy and/or nursing needs are present.

The Bottom Line
SNFs are on the front lines of protecting MA residents. By educating residents and families about appeal rights, promptly delivering required notices, and supporting the appeal process, facilities help ensure that medically necessary care continues—and that coverage decisions are fair, compliant, and clinically sound.

Appeals matter. Persistence matters. And SNFs matter more than ever in helping residents navigate Medicare Advantage coverage challenges.