Skilled Nursing Facility Discharge Appeal Missouri

When a Skilled Nursing Facility Ends Medicare Coverage

A skilled nursing facility (SNF) in Missouri can terminate Medicare-covered services when it determines that the patient no longer requires skilled care. When this happens, the facility must deliver a written Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) at least two calendar days before services are scheduled to end.

The NOMNC tells the family three things: the date that covered services will stop, the reason the facility believes skilled care is no longer necessary, and how to file an appeal. This notice is your trigger to act — the appeal deadline is printed directly on the form.

The Jimmo v. Sebelius Standard: Improvement Is Not Required

The single most important legal precedent for families fighting a skilled nursing facility discharge is Jimmo v. Sebelius, settled in 2013. Before this settlement, Medicare routinely denied continued coverage based on an "improvement standard" — if the patient was not getting measurably better, services were cut.

Jimmo established that Medicare covers skilled services needed to maintain a patient's current condition or to prevent or slow decline. A patient with Parkinson's disease who needs ongoing physical therapy to maintain their current ability to walk does not need to demonstrate improvement. A stroke patient receiving occupational therapy to prevent further loss of hand function qualifies for continued coverage even if full recovery is not expected.

If a SNF tells your family that Medicare will stop paying because your parent has "plateaued" or reached "maximum benefit," ask the facility to document its clinical reasoning in writing and cite Jimmo v. Sebelius in your appeal.

How to File the Appeal

Step 1: Note the deadline on the NOMNC. You must contact Commence Health (1-888-755-5580) by noon on the day after you receive the NOMNC. This is a tight window — do not wait.

Step 2: Call Commence Health. Tell them you want to appeal a skilled nursing facility discharge. They will request the facility's medical records and assign an independent physician reviewer.

Step 3: Services continue during the review. Once the appeal is filed within the deadline, the SNF cannot discharge your parent or terminate Medicare-covered services until Commence Health completes its review. The facility cannot bill the patient for services provided during the review period.

Step 4: Receive the determination. If the reviewer determines that skilled care is still medically necessary, the facility must continue providing services under Medicare. If the reviewer upholds the discharge, the patient becomes financially responsible starting at noon on the day after the determination is issued.

What to Document Before the Appeal

Strengthen your case by gathering specific clinical evidence:

• Current therapy goals that have not been met. If the therapy plan includes specific functional milestones — walking 50 feet with a walker, transferring from wheelchair to bed independently — and these goals have not been achieved, the skilled need is ongoing.
• Maintenance care requirements. Document any skilled interventions the patient needs to prevent decline — wound care, medication management requiring a registered nurse, catheter care, or complex diabetic management.
• Physician statements. Ask the attending physician at the SNF to provide a written statement supporting continued skilled care. A physician who agrees that services should continue but is being overridden by the facility's utilization review department is a powerful piece of evidence.

After the Appeal: Planning the Transition

Even if the appeal succeeds and buys additional days of Medicare-covered care, the family should begin planning the next phase simultaneously. SNF stays are temporary — the question is not whether your parent will leave, but whether the transition is safe when it happens.

Start the DSDS referral for Home and Community-Based Services while your parent is still in the facility. Missouri's Division of Senior and Disability Services requires a clinical assessment before authorizing home care attendants, and the scheduling process can take weeks. Initiating the referral early ensures that home-based support is in place when the SNF stay ends.

The Missouri Hospital Discharge Guide includes the complete SNF appeal workflow, a NOMNC response checklist, and conversation scripts for requesting physician support during the appeal process.

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