Newsroom · Sioux Falls

Medicare says your rehab ends Friday: the Notice of Medicare Non-Coverage, and the free appeal almost nobody files

Two days of warning, a noon deadline, and a review that costs you nothing.

A Notice of Medicare Non-Coverage is the form a nursing home, rehab unit, or home health agency hands you when it has decided Medicare will stop paying, and it starts a clock most families never realize is running. You get at least two days' warning. You have until noon of the next calendar day to demand a free review by an independent organization that does not work for the facility. That review is called a fast appeal, it costs nothing, and in post-acute cases it goes against the payer roughly half the time.

This guide is for the person holding that piece of paper right now, and for the adult son or daughter who got the phone call about it. It explains what the form is, why it usually shows up sooner than the care actually ends, the legal standard the facility is supposed to be applying, exactly how to file the appeal from Sioux Falls, and what the whole thing costs if you let the deadline pass.

Every figure and rule below traces to a source we fetched directly for this article: the federal regulations at 42 CFR § 405.1200 and § 405.1202, Medicare.gov's fast appeals page, CMS's Jimmo Settlement page, CMS's QIO Program Annual Report to Congress for fiscal year 2025, CMS's 2026 Parts A & B cost fact sheet, and the CMS nursing home provider dataset. No numbers from memory.

What a Notice of Medicare Non-Coverage actually is

A Notice of Medicare Non-Coverage is a standardized federal form that four kinds of provider must give you before Medicare-covered services stop. CMS names them: home health agencies, skilled nursing facilities, hospices, and comprehensive outpatient rehabilitation facilities. It is not a bill, not a discharge order, and not a doctor's decision. It's a coverage decision, and it comes with rights printed on the back that the person handing it to you may or may not walk you through.

It usually arrives on a clipboard. Somebody from the business office or social services finds you in the hallway, says Medicare is ending, points at a signature line, and moves on. That is the moment the clock starts, and almost nobody recognizes it for what it is.

Federal regulation is specific about the timing. Under 42 CFR § 405.1200(b)(1), a provider must notify you of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the whole stay is expected to be shorter than two days, you get the notice at admission instead. Medicare.gov states the same rule in plainer words: you should get the notice at least 2 days before covered services end, and if you don't get one, ask for it.

The form itself has to carry five specific things, spelled out in the regulation: the date coverage ends, the date your financial liability for continued services begins, a description of your right to an expedited determination and how to request one, your right to receive a detailed explanation of why, and anything else CMS requires. The blank forms are published on CMS's own notices page, so you can see exactly what yours should look like.

Sources: 42 CFR § 405.1200 — Notifying beneficiaries of provider service terminations, 42 CFR § 405.1202 — Expedited determination procedures, and Medicare.gov — Fast appeals.

Two words in that form are worth defining now, because the rest of this guide depends on them. A benefit period is Medicare's accounting unit for hospital and skilled nursing coverage: it starts the day you're admitted as an inpatient and ends after you've been out of a hospital or skilled facility for 60 days in a row. Skilled care means care that requires the judgment of a licensed nurse or therapist to be delivered safely, as opposed to custodial help with bathing, dressing, and meals, which Medicare has never covered.

Why the notice so often lands around day 15

Medicare covers up to 100 days of skilled nursing care in a benefit period, so families reasonably expect to use something close to 100 days. Most don't come anywhere near it, and CMS has now put a number on why.

In fiscal year 2025, one of the two national review organizations ran a focused review of skilled nursing facility care and Medicare Advantage coverage decisions covering May 2024 through February 2025. CMS reported the findings to Congress, and they're blunt. The review found that 92% of Medicare Advantage beneficiaries still required skilled services when their coverage was terminated, and 72% were at high risk for functional decline or readmission if discharged prematurely. It also found that facilities "often issued NOMNCs around day 15 of care coverage, suggesting administrative timelines were applied rather than individualized recovery in guiding these decisions." Nearly 40% of the cases lacked individualized care goals altogether.

Read that again, because it reframes the whole situation. This is not a fringe complaint from disgruntled families. It's the federal government's own contracted reviewer, reporting to Congress, that in the large majority of the cases it examined the person still needed skilled care on the day the coverage was cut off.

The review found that 92 percent of MA beneficiaries still required skilled services when coverage was terminated, and 72 percent were at high risk for functional decline or readmission if discharged prematurely. CMS QIO Program Annual Report to Congress, FY2025

None of that makes a notice you receive wrong. Plenty of them are correct, and a facility that keeps billing Medicare for care that isn't skilled anymore has its own serious problem. But it does mean the notice is a starting position, not a verdict, and it explains why the appeal outcomes look the way they do.

"You've stopped improving" is not a legal reason

If you ask why coverage is ending and hear some version of "she's plateaued" or "he isn't making progress anymore," you have just been given a reason that federal policy specifically says is not the test. This has been settled for over a decade, and it is still the most common thing families are told.

The Jimmo Settlement Agreement, approved by the court on January 24, 2013, required CMS to revise its own manuals to restate what it calls a maintenance coverage standard. In CMS's own words on that page:

Source: CMS — Jimmo Settlement Agreement (Jimmo Center).

CMS goes further and names the misunderstanding directly, saying the settlement "may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve." The summary line is the one worth memorizing: coverage "does not turn on the presence or absence of a beneficiary's potential for improvement, but rather on the beneficiary's need for skilled care."

A fair caution, because Jimmo gets oversold. It didn't create a new benefit or remove any other requirement. Care still has to be reasonable and necessary, it still has to genuinely require a nurse's or therapist's skill, and the statutory limits still apply, including the 100-day ceiling. What Jimmo removed was one specific bad reason for denial. If that's the reason you were given, say so out loud, by name, when the reviewer calls you. We cover the same standard from the therapy side in our guide to Medicare physical therapy coverage in Sioux Falls.

What doing nothing costs, in 2026 dollars

Here is the arithmetic that makes a phone call worth making. Medicare's skilled nursing benefit is generous at the front and expensive in the middle, and the notice almost always arrives while you're still in the free part, which is exactly why the cost of an early exit is invisible until later.

For 2026, CMS published the figures on November 14, 2025. Days 1 through 20 of a covered skilled nursing stay cost you nothing. Days 21 through 100 cost $217 a day. After day 100 in a benefit period, Medicare's skilled nursing coverage is finished and the bill is entirely yours or your supplement's. The Part A inpatient hospital deductible that opened the benefit period is $1,736.

Source: CMS — 2026 Medicare Parts A & B Premiums and Deductibles (Nov. 14, 2025) and Medicare.gov — Skilled nursing facility (SNF) care, plan year 2026. The $17,360 figure is $217 multiplied by the 80 cost-sharing days.

So picture a real Sioux Falls situation. Your mother broke a hip, spent four nights as an inpatient at a hospital here, and transferred to a skilled nursing facility for rehab. On day 13 you get the notice: coverage ends day 15. She is walking with a walker but not safely, and the therapist is still working on stairs because her house has six of them.

If the appeal succeeds and she gets another three weeks of covered skilled care, days 16 through 20 cost nothing and days 21 through 36 cost $217 each, about $3,472. If it fails and you pay privately for that same care instead, you're paying the facility's own private rate, which Medicare does not set and which the facility will quote you on request. If you skip the appeal and take her home before she can manage stairs, the real cost may be a fall and a second hospital admission, which starts a whole new benefit period and a whole new Part A deductible.

How to file the fast appeal, step by step

You can do all of this yourself, from a hallway, on a cell phone, in about ten minutes. There's no form to download, no lawyer, and no fee. Here's the whole method.

1. Read the date, not the room. Find the coverage end date printed on the notice. Your deadline is noon of the calendar day after you received the notice. Under 42 CFR § 405.1202(b)(1) the request must reach the reviewer "by no later than noon of the calendar day following receipt of the provider's notice of termination." Medicare.gov states the same deadline as noon the day before the termination date. Write the deadline on the notice in pen.
2. Sign it anyway. Signing is not agreeing. It only acknowledges you received the form, and refusing to sign does not buy you time: § 405.1200(b)(4) says the provider can simply annotate the refusal and "the date of refusal is considered the date of receipt of the notice." Refusing costs you the paper trail and gains you nothing.
3. Call the number on the notice. The review organization's phone number is printed on the form. For South Dakota that reviewer is Acentra Health, which covers Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming) and publishes a toll-free beneficiary line of 888-317-0891 on its own helpline page. Use the number on your notice first; it's the one tied to your case.
4. Say the two words. Tell them you are requesting an expedited determination. That's the regulatory term and it routes the call correctly. You can request it by phone or in writing.
5. Give them your side. The regulation requires the reviewer to solicit your views. Be concrete and clinical rather than emotional: what she still can't do safely, what the therapist is still working on, what happens at home. "She can't get up the stairs to her bedroom and there's no bathroom on the main floor" lands better than "she's not ready."
6. Ask for the records. You're entitled to copies of what the facility sends the reviewer, and the provider must accommodate that request by close of business the first day after you ask. They may charge a reasonable copying fee.
7. Name Jimmo if you were told she stopped improving. If the stated reason is lack of progress, say the standard out loud: coverage turns on the need for skilled care, not on potential for improvement.

What happens in the 72 hours after you call

The process from here is tightly scheduled by 42 CFR § 405.1202, and the deadlines fall on the provider and the reviewer, not on you.

Sources: 42 CFR § 405.1200 — Notifying beneficiaries of provider service terminations, 42 CFR § 405.1202 — Expedited determination procedures, and Medicare.gov — Fast appeals.

Once you call, the reviewer notifies your provider. By close of business that same day, the provider must give you a second document called a Detailed Explanation of Non-Coverage. This one is the useful one. Unlike the original notice, it has to state why your services are no longer reasonable and necessary, describe the specific Medicare coverage rule or policy being applied, tell you how to get a copy of that policy, and explain how the rule applies to your particular situation.

The provider also has to hand the reviewer everything it needs, no later than close of business that same day. The reviewer then reads the medical record, asks you why you think coverage should continue, gives the provider a chance to explain its side, and decides. Under § 405.1202(e)(6) that decision comes no later than 72 hours after receipt of the request. Medicare.gov describes the practical timing as by close of business the day after the reviewer has what it needs.

These deadlines are largely met in practice, which is worth knowing if you're afraid of being ignored. CMS reported that across five timeliness measures from May 2024 through September 2025, reviewers hit the standard 99.1% of the time overall, with discharge and service-termination appeal reviews specifically at 96.1% against a 95% target.

If the reviewer sides with the facility

First, the outcome data, because the odds are better than the mood in the hallway suggests. In CMS's report to Congress for fiscal year 2025, Table 6 lists every appeal reviewed from May 2024 through September 2025 and how it came out. "Agreement" there means the reviewer agreed with the payer's or provider's decision to end coverage, so a lower number is better for the person appealing.

Source: CMS — QIO Program Annual Report to Congress, Fiscal Year 2025, Table 6, covering May 2024 through September 2025.

Share of initial appeal reviews in which the reviewer agreed with the decision to end coverage. Source: CMS — QIO Program Annual Report to Congress, Fiscal Year 2025, May 2024 through September 2025.

Post-acute appeals are close to a coin flip, and hospital discharge appeals are much harder. Whether that's because post-acute terminations are genuinely more debatable or because hospital discharge decisions are better documented, the report doesn't say. What it does say is that people are filing far more of these than they used to: from fiscal 2024 to fiscal 2025, post-acute Medicare Advantage appeals rose 28.3%, hospital discharge appeals 12.6%, and post-acute Original Medicare appeals 8.6%.

Change in appeal volume, fiscal year 2024 to fiscal year 2025. Source: CMS — QIO Program Annual Report to Congress, Fiscal Year 2025.

If the decision goes against you, you have a second bite depending on which kind of Medicare you have. Medicare Advantage members and hospital-discharge appellants can ask the same reviewer for a reconsideration, and CMS's table shows 96,897 of those requested in Medicare Advantage post-acute cases, with the original decision upheld 58% of the time. That means roughly 4 in 10 reconsiderations changed something.

Original Medicare post-acute cases work differently. CMS is explicit that reconsideration is available "for all appeal review types except for post-acute Original Medicare appeals," where you go instead to a Qualified Independent Contractor. That's the second of Medicare's five appeal levels, and the ladder continues to an Administrative Law Judge, the Medicare Appeals Council, and finally federal district court. We walk through all five levels in our guide to appealing a Medicare denial.

When the notice itself doesn't count

This is the provision almost nobody knows about, and on the right facts it's worth real money. A Notice of Medicare Non-Coverage only starts your liability if it was delivered properly. If it wasn't, the facility eats the cost, not you.

Section 405.1200(b)(3) defines valid delivery: you, or your authorized representative, have signed and dated the notice to indicate that you received it and can comprehend its contents, and the notice was delivered on time with all the required elements. Then paragraph (b)(5) sets the consequence: "A provider is financially liable for continued services until 2 days after the beneficiary receives valid notice."

Source: 42 CFR § 405.1200 — Notifying beneficiaries of provider service terminations.

None of this is a technicality to wave around for its own sake, and a facility that made an honest paperwork error usually fixes it by reissuing the notice and restarting the two days. That restart is the point. Two more covered days is two more days of therapy, and sometimes two more days is the difference between managing stairs and not.

Medicare Advantage: same clipboard, one extra door

If your coverage runs through a Medicare Advantage plan rather than Original Medicare, the process is nearly identical, which surprises people who expect their plan to control everything. The Medicare Advantage version of the rule lives at 42 CFR § 422.624, and it mirrors the Original Medicare rule: the same 2-day notice, the same independent reviewer, the same fast appeal. Your plan does not get to decide your appeal.

Two differences matter. First, the volume: CMS reviewed 625,608 post-acute Medicare Advantage appeals from May 2024 through September 2025, against 71,453 post-acute Original Medicare appeals, which is roughly nine to one. Second, the extra door. Medicare.gov states that if you miss the deadline for requesting a fast appeal from the reviewer, you can request a fast reconsideration from your plan instead, but with a catch: services are only covered if a decision is issued in your favor. That's a real fallback, and it's a worse one, because missing the deadline moves your money from protected to at-risk.

There's also a plan type built specifically for this setting. An Institutional Special Needs Plan, or I-SNP, is a Medicare Advantage plan sold only to people who live in a nursing facility, and Minnehaha County has two of them for 2026. Their members get the same notices and the same appeal rights as everyone else. We cover how those plans work in our guide to Institutional Special Needs Plans in Sioux Falls.

Where this happens around Sioux Falls

Sioux Falls is a two-hospital-system town, and rehab after a hospital stay usually lands in one of a small number of nearby facilities. There are 96 Medicare and Medicaid certified nursing homes in South Dakota, and just 11 of them in Minnehaha and Lincoln County combined. Here is the whole local list, pulled from the CMS nursing home provider dataset with a CMS processing date of August 1, 2026.

Source: CMS Provider Data Catalog — Nursing homes including rehab services, CMS processing date August 1, 2026. The overall rating is CMS's own published five-star measure; "Not rated" means CMS has not published one for that facility.

Eleven facilities across two counties is a thin bench, and it has practical consequences for a family in this situation. If the appeal fails and you need to move a parent somewhere less expensive, the options within a short drive of Sioux Falls are limited, and the ones in Brandon, Garretson, Dell Rapids, and Canton are each a real distance from a daughter who works downtown. That's a reason to file the appeal on the day the notice arrives rather than spending that day looking for a Plan B.

The other local factor is who your plan lets you use. Minnehaha County has 39,532 Medicare beneficiaries and 15 plans carrying drug coverage for 2026 across 5 carriers. Here is that full roster, since a plan's network is what decides which of the eleven facilities above is actually available to you.

Source: CMS Medicare Advantage / Part D Landscape (PY2026) and CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, plan year 2026. D-SNP plans require Medicaid eligibility; I-SNP plans are for nursing facility residents only.

What your coverage type changes about the bill

The appeal works the same regardless of what you carry. What changes is who pays the $217 a day if the appeal succeeds and the stay runs past day 20.

Under Original Medicare with no supplement, that daily coinsurance is yours. A Medigap policy, also called a Medicare Supplement, can cover it, but not every letter does. Plans A and B, the two most basic standardized designs, carry no skilled nursing coinsurance benefit at all. Here is how the standardized letters handle it.

Source: CMS Publication 02110 — Choosing a Medigap Policy, the CMS standardized benefit chart. Plans C and F are not available to people first eligible for Medicare on or after January 1, 2020. Percentages on Plans K and L are the share the plan pays.

In a Medicare Advantage plan the mechanics differ again. Your skilled nursing cost-sharing is set by your specific plan, usually as a daily copay for a defined stretch of days, and it counts toward that plan's annual out-of-pocket maximum, which Original Medicare does not have. That ceiling is a genuine protection during a long stay. The trade is the network and the prior authorization step. Our Medigap versus Medicare Advantage comparison works through that choice, and the nursing home coverage guide covers what happens after day 100, when South Dakota Medicaid becomes the question.

One more thing about the front door. Original Medicare only covers a skilled nursing stay at all if you had a qualifying inpatient hospital stay of at least 3 days in a row, and Medicare.gov is explicit that time spent under observation or in the emergency room before admission doesn't count, even if you were there overnight. That trap deserves its own read: see Medicare observation status in Sioux Falls.

How a local advisor helps with this

Everything above is something you can do without us, and we'd rather you knew how. Where a local advisor earns the call is in the hour after the notice appears, when you're standing in a hallway trying to figure out whether this is normal and whether you're about to owe somebody a lot of money.

We read the notice with you, find the actual deadline, and confirm which reviewer covers your case. We help you put your reasons in the clinical language the reviewer responds to. If it's a Medicare Advantage plan, we look at what your plan's own documents say about skilled nursing cost-sharing and its out-of-pocket maximum, so you know what a longer stay actually costs before you decide. And when it's over, we look at whether the coverage you're carrying is the right one for the next time, because a hip is rarely the last thing that happens.

What you get is straightforward: the appeal filed inside the window instead of a day late, an accurate picture of your exposure, and somebody local who has read one of these forms before. Big Sioux Benefits is a licensed independent agency here in Sioux Falls, and there is no cost to you for the conversation. You can also get free, unbiased counseling from South Dakota's SHIINE program, which is the state's federally funded SHIP, and we'll tell you when that's the better call.

What to watch

1. The date on the notice, not the day you read it. Your window is noon of the calendar day after delivery, and a Friday notice means a weekend deadline.
2. The reason you're given. "Not improving" is not a valid basis under the Jimmo maintenance standard. Say so.
3. The Detailed Explanation of Non-Coverage. It has to name the actual coverage rule. If it just repeats "no longer medically necessary," ask which policy.
4. Day 20. The $217 a day starts on day 21 in 2026, so the financial stakes of a stay change sharply right about the time a lot of these notices appear.
5. Whether the notice was validly delivered. Late delivery, missing elements, or a signature from someone who couldn't comprehend it can shift liability to the provider under § 405.1200(b)(5).
6. Your annual review. If a skilled nursing stay is now a realistic possibility, the skilled nursing cost-sharing line in your plan or Medigap letter deserves a look before the next Annual Enrollment Period.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references the federal regulations in the eCFR, CMS's own reports to Congress and cost fact sheets, Medicare.gov's beneficiary guidance, and the CMS provider datasets — built by Strategic AI Architects. Every figure on this page was fetched from its primary source on September 1, 2026 and carries the period it covers. This is education, not legal or medical advice; the deadlines on your own notice govern your case, and you should confirm your coverage and costs with your plan, the facility, or a licensed agent. We take no payment from any carrier to feature a plan.