Webinar Questions and Answers

A fee-for-service plan, also known as Original Medicare, is the traditional Medicare program administered by the federal government. Under this payment model, Medicare reimburses providers, including skilled nursing facilities (SNFs), for each covered service delivered, rather than paying a managed care organization a bundled or capitated rate.

Medigap is a Medicare supplemental insurance. It is private health insurance that helps pay for out-of-pocket expenses not covered by Original Medicare (Parts A & B). These out-of-pocket costs can be deductibles, coinsurance, and copayments.

When beneficiaries receive multiple repeated Notices of Medicare Non-Coverage (NOMNCs), it can create confusion and concern about whether Medicare guidelines are being applied consistently. The key issue is not whether guidelines exist. It is how they are applied to the beneficiary’s current clinical condition.

Any entity issuing a NOMNC to a beneficiary receiving care in a skilled nursing facility (SNF) must follow the Medicare coverage guidelines in Chapter 8, Section 30 of the Medicare Benefit Policy Manual. These guidelines define when SNF services are reasonable and necessary and therefore covered under Medicare. Medicare covers SNF care when all of the following are met:

1. The patient requires daily skilled services.
   The beneficiary must need daily skilled nursing care or daily skilled therapy services that:
   • Can only be safely and effectively performed by, or under the supervision of, licensed professionals
   • Are reasonable and necessary for the treatment of the illness or injury

2. The services must be medically necessary.
   The care must:
   • Be needed to improve the patient’s condition or
   • Be required to prevent or slow further deterioration

Coverage does not depend on the patient’s potential for full recovery. A patient may qualify if skilled care is needed to maintain function or prevent decline.

3. The care must require an inpatient SNF setting.
   The services must be of such complexity that they:
   • Cannot be safely provided at a lower level of care
   • Require the resources and professional staff available in a SNF

If these conditions are met, coverage should continue.

Repeated appeals may happen when:

3. • Documentation does not clearly demonstrate the ongoing daily skilled need
   • Goals and treatment plans are not updated to reflect the current function
   • Medicare Advantage (MA) plans rely on timelines rather than individualized clinical review

Importantly, as of January 2025, Medicare policy requires that before issuing a repeat NOMNC, a Medicare Advantage plan must explain in the Detailed Explanation of Non-Coverage (DENC) what specific change in the patient’s condition justifies termination of services after a prior favorable appeal.

Action Steps for Skilled Nursing Facilities

1. Ensure documentation clearly supports daily skilled need.
   • Medical records must be accurate, complete, and up to date
   • Documentation should clearly show:
     • Current level of function
     • Measurable goals
     • Progress toward goals
     • Why daily skilled nursing or therapy is still required

2. Update goals based on clinical status.
   • Goals should be individualized and clinically meaningful
   • Plans of care should be revised when progress or setbacks occur
   • Therapy and nursing documentation should align with established goals and medical needs

   If goals and treatment no longer support daily skilled care:

   • Begin discharge planning promptly
   • Document discharge planning in the medical record
   • Include teaching and training provided to the beneficiary and/or caregiver
   • Address how risks for decline or injury will be mitigated

3. Advocate when you believe a NOMNC is inappropriate.

If you believe an MA plan is issuing inappropriate or repeated NOMNCs:

3. • Provide detailed, written clinical documentation in the medical record
   • Ensure that documentation sent to the BFCC-QIO clearly explains:
     • Current skilled needs
     • Functional deficits
     • Risks of discharge
     • Why SNF-level care remains necessary

Advocacy through strong documentation directly supports appropriate BFCC-QIO review.

Action Steps for MA Plans

Before issuing a NOMNC, MA plans should:

• Conduct a thorough review of the beneficiary’s current medical and therapy needs
• Determine whether daily skilled nursing or daily skilled therapy services are still required
• Ensure decisions are based on clinical status, not timelines

For repeat NOMNCs:

• Clearly document what has changed in the patient’s condition
• Explain how that change supports termination of coverage under Medicare guidelines

Guidance for Beneficiaries Facing Repeated NOMNCs

Beneficiaries who receive repeat notices should:

• Request a QIO appeal promptly
• Ask for a meeting with the SNF staff to review their medical records
• Ensure the record accurately reflects their current condition and need for daily skilled care

Beneficiaries have the right to understand why coverage is ending and how Medicare guidelines apply to their situation.

The beneficiary’s living environment is considered, but BFCC-QIO determinations are ultimately based on clinical need, not location. When reviewing a case, the BFCC-QIO evaluates whether the beneficiary’s current medical condition requires:

• Daily skilled nursing or daily skilled therapy services to safely achieve treatment goals, or
• Whether the same clinical outcomes can be achieved with intermittent skilled services, such as community home health care.

The central question is:
Does the patient require daily skilled services that can only be provided safely and effectively in a skilled nursing facility (SNF)?

Open communication, accurate documentation, and timely reassessment are essential in these situations. When families observe changes that are not reflected in the medical record, it creates understandable concern, particularly if decisions about discharge or transition to a higher level of care are being considered. The medical record should present a complete and accurate picture of the resident’s clinical condition, including both prior and current function.

Key Steps for Care Teams

1. Capture Prior Level of Function (PLOF) accurately.
   A clear and detailed PLOF is critical. This requires:
   • Actively gathering information from family members or caregivers
   • Asking specific, functional questions (e.g., mobility distance, transfers, activities of daily living (ADLs), cognition, endurance)
   • Documenting objective examples, not general statements

Families are often the best source of information about what “baseline” truly looked like before the recent illness or hospitalization.

2. Address documentation gaps promptly.
   If discrepancies are identified:
   • Review the rehab evaluation and nursing documentation
   • Clarify inconsistencies through interdisciplinary discussion
   • Update the medical record to reflect accurate and current information
   • Document any newly reported functional limitations with objective assessment when possible

3. Consider reassessment when appropriate.
   If family concerns suggest a meaningful decline that is not documented:
   • Consider a therapy reassessment
   • Reevaluate strength, mobility, balance, cognition, and safety
   • Compare findings to the documented PLOF

Objective reassessment helps align clinical documentation with observed function.

Supporting Families Through the Process

Care teams should:

• Invite families to care plan meetings
• Review the documented PLOF and current status together
• Explain how functional findings inform discharge or transition decisions
• Ensure the family understands what services can safely meet the resident’s needs

Families often recognize subtle declines first. When their observations are respectfully explored and, when appropriate, incorporated into the clinical record, care decisions are stronger and more defensible.

SNFs should begin discharge planning early, reassess it throughout the stay, and actively involve the beneficiary and family in care decisions. If these standards are not met, there are formal mechanisms to ensure accountability.

If issues related to:

• Failure to initiate discharge planning early
• Lack of ongoing communication with families
• Inadequate coordination regarding transitions of care
• Insufficient documentation of discharge discussions

Rise to the level of a quality of care (QOC) concern, they should be reported to the BFCC-QIO as a QOC matter.

Submitting the concern as a QOC ensures it is:

• Formally reviewed
• Evaluated against evidence-based guidelines
• Addressed through established oversight processes

When making a referral, it is important to include:

• The beneficiary’s identifying information
• Specific dates of stay
• A clear description of the concern

Beneficiaries and their families may also bring concerns directly to the BFCC-QIO QOC team. Their perspective is critical and often helps identify issues early, before they escalate. Encouraging beneficiaries to voice concerns supports transparency and strengthens the overall care process.

There is also a significant opportunity for Medicare Advantage (MA) plans to proactively partner with SNFs to strengthen discharge processes.

Health plans can:

• Reinforce expectations for early and ongoing discharge planning
• Encourage timely interdisciplinary care conferences
• Promote consistent family communication
• Support facilities in strengthening documentation practices

Collaboration between plans and facilities can improve both the quality of services provided and the documentation supporting care decisions. Strong documentation, in turn, supports smoother transitions and reduces avoidable disputes.

Communication with families should begin at admission, not at the point when a NOMNC is issued. When conversations happen only at the end of coverage, families may feel surprised or unprepared. Early and ongoing engagement helps prevent that situation.

It is considered best practice for the skilled nursing facility (SNF) team, including social workers and case managers, to meet with the beneficiary and family early in the stay to:

• Discuss the patient’s goals
• Review the plan of care
• Explain how progress will be measured
• Clarify what discharge readiness will look like
• Outline potential next levels of care

Having this conversation at the beginning, often on day one, helps set clear expectations and allows families time to prepare for a safe and successful transition.

Beneficiaries and families are encouraged to:

• Request a consultation with the social worker early in the stay
• Ask for care plan meetings
• Request updates on progress toward goals
• Clarify anticipated discharge timelines

Cognitive impairments should be carefully and thoughtfully considered as part of a comprehensive assessment of both prior and current function. They are an important clinical factor, but they do not automatically determine whether skilled services are appropriate.

When evaluating prior level of function (PLOF) and the highest functional performance, care teams should consider:

• How the beneficiary functioned in their usual environment
• The level of cueing, supervision, or assistance required
• Whether routines, familiarity, or caregiver support allowed higher performance at baseline

Cognitive impairment may mean that a beneficiary performs differently in unfamiliar settings, such as after hospitalization. A structured SNF environment may temporarily affect performance, either positively (due to support) or negatively (due to confusion or change in routine).

Accurate PLOF requires input from:

• Family members or caregivers
• Prior medical records
• Objective assessments

When determining whether daily skilled services are reasonable and medically necessary, the key considerations include:

• Does the beneficiary require skilled professional services to improve function, maintain function, or prevent decline?
• Are skilled techniques, clinical judgment, or ongoing assessment required?
• Is the complexity of the condition such that services must be performed by or under the supervision of licensed professionals?

Cognitive impairment alone does not preclude skilled care. Many individuals with cognitive deficits benefit from skilled nursing or therapy services, particularly when structured interventions, cueing strategies, or safety training are required.

If cognitive impairment significantly limits the beneficiary’s ability to engage safely or effectively in therapy, care teams should:

• Assess whether modifications, cueing strategies, or environmental adjustments improve participation
• Determine whether skilled services remain necessary for safety, maintenance, or prevention of decline
• Document objective observations clearly

If daily skilled services are no longer required, discharge planning should begin promptly and be clearly documented. When cognitive impairment affects function, early caregiver involvement is essential. This may include:

• Teaching and training on safe mobility, transfers, or activities of daily living (ADLs)
• Education on behavioral or safety strategies
• Instruction on preventing further decline

When medically necessary, caregiver training may itself require skilled professional involvement. Early engagement helps ensure a safe transition and reduces risk after discharge.

Chronic illness and socioeconomic challenges absolutely affect a beneficiary’s health, safety, and overall outcomes. However, when it comes to Medicare skilled nursing facility (SNF) coverage decisions, the determining factor is medical necessity, not geography, income level, or social circumstances.

Under the Medicare Benefit Policy Manual, Chapter 8, Sections 30 and 30.3, coverage in a SNF requires that the beneficiary need:

• Daily skilled nursing services or daily skilled rehabilitation services. These services require the skills of qualified professional personnel (such as nurses or licensed therapists) to ensure safety and achieve the medically desired result.

A service is not considered skilled simply because a nurse or therapist performs it. If the service can be safely and effectively carried out by an unskilled person, it is not considered skilled under Medicare rules. Likewise, the lack of a capable caregiver,even if that creates hardship, does not by itself convert a non-skilled service into a skilled one.

Chronic conditions are evaluated based on:

• The complexity of the condition
• The need for skilled assessment, monitoring, or intervention
• Whether skilled care is required to improve, maintain, or prevent deterioration

For example, a chronic condition that requires ongoing skilled nursing judgment or complex therapy may support SNF-level care. However, the mere presence of a chronic diagnosis does not automatically qualify someone for daily skilled services.

Socioeconomic challenges—such as limited family support, housing instability, or financial hardship—are deeply important to care planning and safe discharge. Care teams should absolutely take these into account when:

• Developing discharge plans
• Arranging community services
• Coordinating caregiver support
• Identifying safety risks

However, under Medicare coverage rules, social factors alone do not determine eligibility for skilled nursing facility coverage. Coverage decisions must be based on whether daily skilled services are medically necessary.