Many families report getting caught off guard when Medicare or their insurance suddenly stops covering their loved one’s stay in a nursing home. Patients have also shared the same stories. Often, the termination notice says the patient is “no longer improving” or that their recovery has “plateaued.” Being told this news can already feel like a blow. However, it does not mean that coverage has to end.
Here’s the good news. You have the right to appeal, and you may still be eligible for continued care even if you are already stable.
According to the federal court case of Jimmo vs. Sebelius, Medicare cannot legally deny coverage simply because someone has stopped improving. Coverage can still apply when an individual needs skilled care to maintain function or prevent deterioration.
Below, we outline the steps to take upon the termination of your nursing home coverage. Although focused primarily on Medicare, they also apply to Medicaid managed care and private insurance, with modifications. We have also provided resources and sample letters to help you with your appeal.
Step 1. Review and Understand the Termination Notice
If your Medicare coverage is ending, the facility must provide a written notice.
- Traditional Medicare: You’ll receive a “Notice of Medicare Non-Coverage” (NOMNC).
- Medicare Advantage Plans: You’ll receive a similar form specific to your plan.
- Private Insurance: The notice will show when and why your coverage is ending, and how to appeal.
Pay attention to:
- The stated reason for ending care (e.g., “not improving,” “no longer needs skilled care,” or “condition has plateaued”)
- The effective date of termination
- Appeal instructions and deadlines
Important: Even if the nursing home agrees with the decision, you still have the right to challenge it.
Step 2. Act Quickly, You Have a Limited Time To Appeal
To request a fast and expedited appeal, you must act by noon the day before coverage is scheduled to end.
For traditional Medicare, contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) assigned to your state.
For example, in Florida:
KEPRO (BFCC-QIO for Florida)
Phone: 1-888-317-0751
Website: www.keproqio.com
If you have a Medicare Advantage plan, call the number on the back of your insurance card to initiate the appeal. Your plan will guide you through its process.
Step 3. Understand the Appeal Process and Your Rights
You are entitled to a fast appeal of Medicare’s decision to terminate your nursing home coverage. When you file a timely appeal, the nursing home must continue to provide care until the QIO releases their decision.
Medicare has five levels of appeal.
| Level | Appeal To | Timeframe |
| 1 | QIO (Fast Appeal) | By noon the day before coverage ends |
| 2 | Qualified Independent Contractor (QIC) | Within 60 days of Level 1 denial |
| 3 | Administrative Law Judge (ALJ) | Within 60 days of Level 2 denial |
| 4 | Medicare Appeals Council | With 60 days of Level 3 denial |
| 5 | Federal District Court | Final level (judicial review |
You may go through a different appeal process if you have a Medicare Advantage plan or private insurance. However, the steps will be generally similar. To be sure, check your plan documents or call your insurer for details.
Step 4. Strengthen Your Case
You must gather the documents below to back up your appeal.
- A letter from the treating physician or therapist stating why skilled care is still medically necessary
- A list of ongoing skilled services the patient is receiving (e.g., physical therapy, wound care, IV medications), not just custodial care
- Progress notes, care plans, and therapy evaluations showing how the patient is benefiting or would decline without care
Key points you must focus on:
- Skilled care is still necessary for deterioration prevention
- The patient has a complex condition needing monitoring or therapy
- Stopping care could lead to serious harm or hospitalization
Important Legal Precedent:
A federal court clarified in the 2013 Jimmo v. Sebelius settlement that Medicare must cover skilled nursing care even if a patient is not improving, as long as the services are:
- Necessary to maintain current function
- Required to prevent or slow decline
- Ordered by a physician and medically necessary
Unfortunately, many providers still mistakenly deny coverage based on an “improvement standard.” If your termination notice says the patient has “plateaued, cite the Jimmo case in your appeal.
For more information, visit the Center for Medicare Advocacy’s Jimmo resource page.
Step 5. Submit the Appeal to the QIO
As soon as you have everything in hand, you can already:
- Provide a straightforward statement against the coverage termination
- Explain the reasons behind the patient’s continued need for skilled services
- Refer to Jimmo v. Sebelius and the Centers for Medicare & Medicaid Services (CMS) rules, where necessary
- Submit your verbal or written appeal to the proper channels
Once submitted:
- The QIO will review the case within 24 to 72 hours
- The facility must provide a detailed explanation of why care is ending
- The QIO will issue a decision (typically within two days)
Step 6. What If the Appeal Is Denied?
Don’t give up. Most families win appeals at higher levels when they persist.
If the first-level fast appeal is denied, you can request the Qualified Independent Contractor (QIC) for a reconsideration. You must submit this within 60 days of the denial. At this stage, consider getting help from:
- An elder law attorney, especially if you’re experiencing multiple denials or facing a complex case
- A local counselor from the State Health Insurance Assistance Program (SHIP) (www.shiphelp.org)
Step 7. Special Considerations for Private Insurance Appeals
If you have a private insurance policy (not Medicare), your rights vary by state and insurer.
However, you are generally entitled to:
- An internal appeal
- An external review conducted by an independent medical reviewer
Check your Explanation of Benefits (EOB) and appeal notice for exact steps and deadlines.
Summary Table
Steps Action Deadline
| 1 | Receive NOMNC or denial letter | |
| 2 | Request Fast Appeal to QIO | By noon day before coverage ends |
| 3 | Submit documentation | ASAP (ideally with initial appeal) |
| 4 | Receive QIO decision | Within 2 days |
| 5 | If denied: Appeal to QIC | Within 60 days |
| 6 | Continue through next levels as needed | Each with 60-day windows |
Understanding Jimmo v. Sebelius Settlement Better
The Jimmo v. Sebelius case was a federal class-action lawsuit resolved in January 2013. It clarified that Medicare coverage for skilled nursing or therapy services doesn’t depend on whether a patient is expected to improve. Instead, coverage is based on whether skilled care is medically necessary.
Why It Mattered
Before the case, many people were denied Medicare coverage because of the mistaken belief that care was only covered if it would lead to what is known as the “Improvement Standard.” The Jimmo settlement corrected this misunderstanding.
Now, Medicare can cover skilled services needed to maintain a person’s current condition or slow further decline, even if there’s no expectation of recovery. These include services delivered at home, in skilled nursing facilities (SNFs), outpatient therapy, and in many cases, inpatient rehabilitation facilities (IRFs).
What Changed After the Settlement
CMS updated its rules and issued clearer guidance on the proper standards. It also launched a national education campaign informing healthcare providers, contractors, and decision-makers of the changes. CMS committed itself to reviewing claims to ensure the new standard is being applied properly.
How Medicare Makes Coverage Decisions Post-Jimmo
Under the clarified standard, Medicare may cover skilled care when:
- Needed to sustain function or prevent deterioration, regardless of improvement.
- The patient can’t safely perform the care on their own or receive it from unskilled caregivers.
If these conditions are met, and other Medicare rules are followed (like medical necessity), then the service should be covered, even for people with chronic or progressive conditions.
Ongoing Issues
Despite the settlement, confusion still exists. Some healthcare providers and contractors continue to deny care based on the outdated idea that improvement is required. Advocates continue pushing for better enforcement of the Jimmo standard.
What Jimmo Means for Beneficiaries
Jimmo is especially important for individuals with long-term or stable conditions. They may now qualify for skilled care such as physical therapy to slow mobility loss or nursing services for chronic wound care, even if there’s little hope of improvement.
If someone was denied Medicare coverage after January 18, 2011, because of the “Improvement Standard,” they may request a review to have the denial reconsidered.
The Bottom Line
Medicare can cover skilled care not only to help people get better, but also to help them stay as well as possible. Supporting quality of life is a valid and important goal under Medicare.
Trusted Resources for Medicare Claims and Appeals
When dealing with a Medicare denial, these resources can help you understand your rights. You will need them, especially when you’re looking for guidance on maintenance of care or the Jimmo v. Sebelius settlement. They can also guide you through the appeals process.
1. Center for Medicare Advocacy (CMA)
Website: www.medicareadvocacy.org
- Provides clear-cut guides for Medicare appeals.
- Offers sample letters and legal arguments tailored to Jimmo denials.
- Shares regular updates on CMS guidance and enforcement actions.
- Direct Jimmo Resource Page: https://medicareadvocacy.org/jimmo-v-sebelius-improvement-standard-case-summary
2. Medicare.gov – Claims and Appeals
Website: www.medicare.gov/claims-appeals
- Learn how to file an appeal after a denial.
- Understand the time limits and process for each level of appeal.
- Find where to send your documentation.
- Download your Medical Summary Notices (MSNs).
- Use the MyMedicare.gov portal to track your claims and appeals.
3. State Health Insurance Assistance Program (SHIP)
Website: www.shiphelp.org
- Offers free, local, one-on-one Medicare counseling from trained volunteers.
- Help with understanding denial letters, completing appeal forms, and meeting deadlines.
- Provides tailored guidance on Medicare claims and appeals,
- Find your local SHIP office: https://www.shiphelp.org/about/state-programs
4. Medicare Beneficiary Ombudsman
Website: https://www.cms.gov/center/ombudsman.asp
- Assists with difficult or chronic Medicare issues.
- Promotes fair processes for appeals and dispute resolutions.
- Accept reports about systemic problems, such as the misapplication of the Jimmo settlement,
5. Your Medicare Advantage or Part D Plan’s Appeals Department
- For those with a Medicare Advantage (Part C) or Part D drug plan, you can appeal directly through your plan by following the steps below:
- Request a “reconsideration” of your denied service or medication.
- Ask for the clinical reasoning behind the denial in writing.
- Reference the Jimmo v. Sebelius case if the denial is based on a lack of improvement rather than the need for maintenance care.
Sample Letter Templates and Guides
You can modify the sample appeal letter below based on your needs.
[Date]
[Your Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
To: [Name of QIO or Insurance Appeals Dept.]
e.g., KEPRO [QIO Address or Fax Number]
Re: Fast Appeal of Medicare Termination of Skilled Nursing Facility Coverage
Patient Name: [Full Name]
Medicare Number: [Patient’s Medicare ID]
Date of Birth: [DOB]
Facility Name: [Nursing Home Name]
Facility Address: [Address]
Date of Termination Notice: [Insert Date]
Effective Date of Termination: [Insert Date Coverage Ends]
Dear [QIO/Insurer Name or “To Whom It May Concern”],
I am writing to appeal the proposed termination of Medicare (or insurance) coverage for skilled nursing facility services for [Patient’s Full Name]. We received the notice on [Date] stating that coverage is ending due to the “plateauing” condition of the patient.
This rationale is inconsistent with Medicare policy, clarified in the 2013 Jimmo v. Sebelius case. According to the settlement, Medicare coverage must be extended to patients, even if they do not show signs of improvement.
It further stresses that coverage may be continued when the maintenance of function needs skilled care. The same goes for the prevention of decline or the management of a complex medical condition, even without the expectation of full recovery.
[Patient’s Name] continues to require skilled nursing care, including:
- [List skilled services, such as physical therapy, wound management, IV care]
- [Mention risks of stopping care: e.g., increased falls, infection, readmission]
Attached are medical records and a letter from the treating physician confirming the need for continued skilled services. I request an immediate review and continuation of coverage.
Sincerely,
[Your Name]
[Relationship to Patient, if applicable, e.g., Daughter/POA]
[Phone and Email]
Attachments:
- Physician’s letter of medical necessity
- Recent therapy and nursing progress notes
- Care plan
- Copy of Termination Notice
- Proof of representation or authorization documentation (if applicable)
You Can Ask for Help
Being told that Medicare or insurance won’t cover nursing home care anymore can feel overwhelming. However, you don’t have to accept it. Appealing a termination is your legal right. With the right documentation and persistence, you have a strong chance of success.
Aside from a SHIP counselor, we at Scott Law Offices can help you with your appeal if you need someone to guide you through the next steps. Don’t give up. Your loved one’s care may depend on it.