As Medicare Advantage (MA) enrollment continues to grow, skilled nursing facility (SNF) staff are increasingly navigating coverage terminations, expedited appeals, and questions from residents and families about their rights. Recent scrutiny from regulators and Quality Improvement Organizations (QIOs) has intensified focus on MA coverage decisions involving skilled nursing care.

In June 2026, the Office of Inspector General reported that MA plans overturned nearly all appealed prior authorization denials for SNF admissions, raising concerns about the appropriateness of some initial denials and whether beneficiaries fully understand their appeal rights. Although the report focused on admission denials rather than coverage terminations after admission, it reflects growing federal oversight of MA plan decision-making.

At the same time, organizations such as Acentra Health have identified concerns regarding MA coverage terminations within SNFs, including repeated Notices of Medicare Non-Coverage (NOMNCs) and the importance of individualized clinical review. Together, these developments underscore the need for SNF staff to ensure residents understand their appeal rights and that documentation clearly supports ongoing skilled care needs.

Acentra is one of the two federally contracted Beneficiary and Family-Centered Care (BFCC) QIOs.

Current Clinical Need

MA plans are required to follow Medicare coverage criteria when determining whether SNF services remain medically necessary. Contrary to popular belief, coverage does not depend solely on a resident’s potential for full recovery. Skilled services may remain covered when needed to maintain function or prevent or slow further decline.

The BFCC QIOs have noted concerns regarding repeated NOMNCs and situations where decisions appear to rely on timelines rather than individualized clinical review. For SNF leaders, this situation reinforces the importance of ensuring documentation clearly demonstrates the resident’s current condition, skilled needs, functional limitations, and risks associated with discontinuing services.

Understanding Appeal Rights

When an MA plan determines coverage should end, residents must receive a NOMNC explaining their right to request an expedited review by the BFCC-QIO. Because residents and families may mistake the notice for a final decision, SNF staff should explain what the notice means, the resident’s appeal rights, and applicable timelines.

Staff must also be prepared to discuss the resident’s current clinical condition, ongoing skilled needs, progress toward goals, discharge readiness, and the facility’s recommendations for continued care. These conversations help residents and families understand how Medicare coverage criteria apply to the resident’s situation. But at the same time, staff must be careful not to influence their decision.

Communication should be ongoing throughout the stay, not only when the NOMNC is issued. Ongoing updates about clinical progress, discharge planning, and coverage expectations help residents make informed decisions. For repeat NOMNCs following a favorable appeal, MA plans must explain the specific change in condition that supports ending coverage, possibly warranting closer facility review.

Documentation Is the Strongest Advocacy Tool

When appeals occur, reviewers rely heavily on the medical record. Documentation should clearly support these factors:

• Need for daily skilled nursing or therapy services;

• Current functional status and clinical complexity;

• Progress toward individualized goals;

• Ability to maintain function or prevent decline;

• Risks associated with discharge or discontinuation of services; and

• Why the services needed require the skills of licensed nurses or therapists.

Acentra Health emphasizes that records should clearly describe current function, measurable goals, progress, and ongoing skilled need. Weak or incomplete documentation can undermine an otherwise appropriate case for continued coverage.

Family Engagement Matters

Families frequently identify functional decline, safety concerns, or barriers to discharge not fully reflected in the medical record. SNF leaders should encourage interdisciplinary review when family observations differ from documented assessments and consider reassessment when warranted.

Equally important, discharge planning ideally begins at admission and continues throughout the stay. Families should understand goals, anticipated discharge needs, and potential transition plans long before a NOMNC is issued. Early communication lessens confusion, improves trust, and supports more successful transitions.

Leadership Takeaways

As MA plan enrollment grows, SNF leaders will be challenged by continued scrutiny of coverage determinations and appeals. Leaders can best support residents by ensuring staff understand appeal rights, engaging families early after admission, promoting interdisciplinary communication, and maintaining strong clinical documentation. Residents need not view a NOMNC as the end of the conversation. Instead, it should prompt a careful review of the resident’s current skilled needs and ensure that he or she has the information necessary to make informed decisions about ongoing care.

Jennifer LaBay, RN, RAC-MT, RAC-MT, CRC, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).