My elderly mother is in a nursing home. She recently received her SNF ABN Notice of Medicare non-coverage for continued skilled nursing services, meaning from now on, until she (hopefully eventually) gets Medicaid, those very high expenses are coming out of her small life savings.
I requested an immediate appeal to the QIO and they upheld the initial decision.
I would have to ask for an immediate reconsideration by noon on 8/18/26 (tomorrow), but I'm feeling like it's not worth it because I don't have any new info or even an argument as to why the initial decision was wrong because I don't even have the details on the basis of the decision yet.
Does anyone with experience on this have any advice for me?
Request the reconsideration before today's noon deadline. You don't have to have new evidence in hand in order to request it. You can continue gathering information after you've preserved your appeal rights.
Also immediately ask for the Detailed Explanation of Non-Coverage and the QIO's written decision so you know exactly why they concluded that Medicare coverage should end. Medicare says that detailed notice should explain the reason coverage is ending, the Medicare coverage rule being applied, and the basis for the decision.
Then talk to her nurses, therapists and physician and ask a very specific question: What skilled nursing or skilled therapy does Mom still require that must be provided by or under the supervision of skilled personnel? Ask them to document those needs. The argument isn't simply that Mom still needs a nursing home or isn't safe to go home. Medicare's SNF benefit is for skilled care, not indefinite custodial long-term care.
Don't let today's deadline pass simply because you don't yet know whether you'll win. At nursing-home private-pay rates, even a relatively short additional period of Medicare coverage can represent thousands of dollars. File the reconsideration, get the reasoning behind the denial, and then decide how far you want to pursue it.
At the same time, continue the Medicaid application and financial planning. Winning another period of Medicare SNF coverage would buy time, but it won't eliminate the need for a long-term payment plan if Mom has transitioned from needing Medicare-covered skilled care to primarily custodial nursing-home care.
Medicare only pays 100% the first 20 days. 21 to 100, 50%. You need to have a good supplimental that pays the other 50%. For my Mom (9 yrs ago) she paid $150 a day.
Yes, if Mom needs to stay in care, then her savings will have to pay for her care. Medicaid is for people that have no other assets then their monthly income and maybe a home. My Mom had 20k which paid for 2 months which gave me time to apply to Medicaid and get info needed together. She paid May and June. June I confirmed Medicaid had everything and July 1st Medicaid started. My State gives you 90 days to complete the application.
You're right, you have no real basis for your argument to reconsider the appeal.
Be glad your mother has that small life savings. Do you expect your mother to "recover" sufficiently to leave the skilled nursing facility and return home?
If she is there for the long term, then applying for Medicaid is exactly what you do and in the meantime, her savings will have to cover the costs of care.
You can talk with someone who manages the billing for the SNF, if you're worried about her running out of funds. Typically they will work with you. You might not even need to make a payment until the Medicaid application has been processed, because Medicaid will pay retroactively. My husband was in a SNF for 9 months before I was contacted by the billing person. My employer's health benefits covered a period of time, as Medicaid was being processed; then when Medicaid determined my husband's share of cost, I owed $1400/ month retroactive - going back 4 or 6 months. We had NO savings at that time, only income, a rental apartment and a 20 yr old car.