Earlier this year, the Center for Medicare Advocacy highlighted updated CMS appeals guidance to Medicare Advantage plans. Effective January 1, 2025, if an MA plan’s decision to terminate coverage with a Notice of Medicare Non-Coverage (NOMNC)[1] is overturned on appeal, before issuing another NOMNC, the plan must be able to explain what has changed to warrant another attempted coverage termination. This explanation must be included in a Detailed Explanation of Non-Coverage (DENC), which is a required notice that provides a reason for termination if the enrollee disagrees and chooses to appeal.
The Center presumed this guidance was in response to the alarming trend of MA plan’s repeatedly issuing NOMNCs to enrollees and refusing to abide by appeals decisions. We have long-witnessed repeated and harassing NOMNCs from MA plans. Unfortunately, despite this new guidance, we continue to hear from enrollees who successfully appeal NOMNCs only for their MA plans to issue another NOMNC within days.
In one recent example, an MA Plan issued a NOMNC to an enrollee in a skilled nursing facility, stating that she no longer required skilled physical and occupational therapy five days per week, or each weekday, despite current physician’s orders. The enrollee appealed, and a Medicare contractor held that the MA plan should continue providing coverage because the therapy continued to be medically necessary. This decision was made just before a holiday weekend. On Monday morning, the enrollee received another NOMNC from the plan, even though therapy was not provided over the weekend and no new information was available.
In situations like these, the Center is generally advising enrollees and their representatives as follows:
- Continue to appeal. Don’t give up. We have witnessed enrollees successfully appeal five or more consecutive NOMNCs.
- Insist on receiving a copy of the DENC from the plan, which MA plans are required to deliver promptly pursuant to 42 C.F.R. § 422.626(e).
- Review the DENC for compliance with CMS’s new appeals guidance (link here, see page 133, § 100.2.1).
- Retain the DENC, and if it does not comply with CMS’s guidance,
- alert the appellate decisionmaker, and
It is important to note that there is no stated consequence for an MA plan’s failure to comply with this new guidance. It is up to beneficiaries and their representatives to monitor for compliance and report noncompliance to Medicare contractors and by filing grievances.
[1] As a reminder, enrollees receiving covered skilled nursing facility, home health, or comprehensive outpatient rehabilitation facility services must received a NOMNC, delivered by the facility or provider, before coverage is terminated and their services end. The NOMNC contains instructions on appealing the termination.
October 2, 2025 – E. Krupa