When the nursing home says Medicare is ending: the NOMNC and the fast appeal

The NOMNC is a two-page federal form, CMS-10123. Skilled nursing facilities (SNFs), home health agencies, outpatient rehab facilities and hospices must use it when Medicare-covered services are ending (CMS form instructions). It states the last covered day, the date the patient becomes responsible for the cost, and how to ask for a fast appeal (42 CFR 405.1200).

In a nursing home, it usually means the facility believes the person no longer needs daily skilled nursing or therapy. It doesn't mean they must leave. It means Medicare Part A may stop paying, and someone else, whether the patient, a supplement plan, long-term care insurance or Medicaid, would pay for any further days.

A NOMNC isn't required when one service is cut but others continue, for example when occupational therapy stops and physical therapy goes on (Medicare Claims Processing Manual, ch. 30, §260.2.1).

CMS says the patient or representative must be able to understand the notice and should sign and date it (CMS form instructions). Signing only confirms receipt. It isn't agreement. If the patient refuses to sign, the facility notes the date, and the right to appeal remains (ch. 30, §260.3.5).

If the patient can't understand it, for example because of dementia, the notice goes to a representative, such as an agent under a health care surrogate designation or durable power of attorney. A representative who doesn't live with the patient may be told by phone, and the date of that call counts as the date of receipt (ch. 30, §260.3.8). Write down the date and time of any call.

The appeal goes to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), an independent reviewer under contract with Medicare (Medicare.gov). For Florida, that is Acentra Health, at 1-888-317-0751 (Acentra Health). The line is open 9 a.m. to 5 p.m. on weekdays and 10 a.m. to 4 p.m. on weekends and holidays, Eastern time (Acentra Health).

The deadline is noon of the calendar day after receiving the notice (42 CFR 405.1202(b)(1)). With a notice delivered 2 days ahead, that is noon the day before coverage ends, as Medicare.gov describes it. Call. The request can be made by phone, and there's no fee.

The patient doesn't have to prove anything. The facility has the burden to show that ending coverage is correct (405.1202(d)). It helps to tell the reviewer why skilled care is still needed. Maybe a wound still needs nursing care, a new medicine needs monitoring, or therapy is preventing decline. Ask the doctor to call too.

Acentra notifies the facility. By close of business that day, the facility must give the patient a Detailed Explanation of Non-Coverage (DENC), form CMS-10124, explaining why it believes coverage should end and which Medicare rule it relies on (405.1202(f); CMS). You can ask for copies of what the facility sends the reviewer.

Medicare.gov says the reviewer usually decides by close of business the day after it has the information it needs. The regulation's outside limit is 72 hours after the request (Medicare.gov; 405.1202(e)(6)).

If you win: Medicare coverage may continue, subject to the usual coinsurance, until a new notice is issued. If you lose: the patient isn't billed for days before the end date on the notice. Days after that may be private pay. A next-level fast reconsideration with a Qualified Independent Contractor (QIC) must be requested by noon of the day after hearing the decision. The QIC generally decides within 72 hours (42 CFR 405.1204). If you miss noon: Acentra still accepts the request and decides as soon as possible. But the 72-hour timeline and the billing protection don't apply (405.1202(b)(4)).

Medicare Advantage plan members get the same NOMNC, but the fast appeal follows the plan rules. The request deadline is also noon of the day after delivery (42 CFR 422.626). The NOMNC itself names the reviewer to call.

These notices are often confused. The NOMNC says covered care is ending and gives fast-appeal rights. An Advance Beneficiary Notice shifts the financial risk to the patient for a specific item or service Medicare is expected not to pay (CMS). One doesn't replace the other. If a patient's Part A stay ends but they stay on for custodial care, the facility must give the NOMNC 2 days ahead and a SNF ABN before custodial care begins (ch. 30, §261).

Whatever the outcome, a NOMNC is a signal to plan. If the person will stay as a long-term resident, the cost may be private pay, possibly over $10,000 a month, unless Medicaid applies. Florida uses $10,645 as the average monthly private-pay cost when figuring transfer penalties (DCF Appendix A-9). Medicaid eligibility generally starts no earlier than the first day of the month the application is received. So filing before the month ends can matter (ESS 0640.0502).

If the person is going home, ask for the discharge plan in writing, including home health orders and equipment.