Medicare cannot physically remove you from a rehabilitation facility, but it can stop paying for your stay, and in practice that is what people mean when they ask whether Medicare can kick you out of rehab. Before coverage ends, the facility has to hand you a written notice at least two days in advance, and you have the right to an immediate, independent appeal that keeps you in the facility at no cost while a reviewer checks the decision. The rules give you real protection, but only if you act inside a very short window.
Why Coverage Gets Cut Before You Feel Ready to Leave
The single most common reason Medicare stops paying for a rehab stay is a determination that your care no longer needs to be delivered by licensed medical professionals. Medicare Part A pays for skilled care: services ordered by a physician, performed or supervised by licensed staff such as registered nurses or physical therapists, and required on a daily basis for a condition tied to your qualifying hospital stay.1eCFR. 42 CFR 409.31 – Level of Care Requirement Wound care, IV medications, and therapy sessions qualify.
What Medicare does not pay for in a nursing facility is custodial care: help with bathing, dressing, eating, and moving around. Any of that a non-medical caregiver could safely provide. The moment the facility’s clinical staff decides your remaining needs are custodial, they have grounds to end your Medicare-covered stay, even if you still cannot manage at home.
This judgment is inherently subjective, and it is where most disputes begin. A therapist may downgrade your level of care after a session that felt like any other. Families often feel blindsided. Knowing where the line falls, and pushing back on how it is being drawn, is the whole game.
You Don’t Have to Be Improving
For years, facilities treated Medicare rehab coverage as an improvement benefit: if the patient stopped getting better, coverage stopped. The Jimmo v. Sebelius settlement rejected that. Medicare must cover skilled services needed to maintain your current condition or slow further decline, provided those services genuinely require a licensed professional’s expertise.2Centers for Medicare & Medicaid Services. Frequently Asked Questions Regarding Jimmo Settlement
The catch is documentation. A therapist keeping a stroke patient’s mobility from deteriorating is providing skilled care, but only if the medical record explains why professional expertise is necessary and what would happen without it. Thin notes are the most common reason a legitimate maintenance claim gets denied. If you sense coverage is about to end, ask the treating therapist directly whether the maintenance rationale is documented in the chart.
The Notice That Starts the Clock
Before a facility can stop billing Medicare, it must give you a written Notice of Medicare Non-Coverage (form CMS-10095) at least two days before your covered services end.3Centers for Medicare & Medicaid Services. Form Instructions for the Notice of Medicare Non-Coverage CMS-10095 The notice states the exact date you become financially responsible and lists the name and phone number of your regional Beneficiary and Family Centered Care Quality Improvement Organization, known as the BFCC-QIO.4Centers for Medicare & Medicaid Services. FFS and MA NOMNC/DENC
You or your representative will be asked to sign. That signature only confirms receipt; it does not mean you agree. Write down the QIO number before you sign, because the appeal window is measured in hours.
The Fast Appeal That Keeps You in the Bed
As soon as you get the notice, you can call the BFCC-QIO on the form and request an expedited review. To keep the strongest protection against being billed while the review is pending, call no later than noon of the first working day after you receive the notice.5Centers for Medicare & Medicaid Services. Appendix 3 – Notice of Discharge and Medicare Appeal Rights Missing that deadline does not destroy your appeal rights, but you may start owing money before a decision comes down.
Once you file, the facility has to send the QIO a Detailed Explanation of Non-Coverage by close of business the same day, spelling out why it thinks your skilled care should end.6Centers for Medicare & Medicaid Services. Notice Instructions for the Detailed Explanation of Non-Coverage (DENC) The QIO reviews your full medical record, not just the facility’s summary, and issues a decision quickly. If the QIO agrees with you, coverage continues. If it agrees with the facility, you either leave or begin paying the daily private rate.
The process is designed to be fast and does not require a lawyer. The call itself takes minutes. The hardest part is acting inside the window, especially when the patient is elderly and family members are scattered. Naming a healthcare representative before a crisis saves critical time.
If the QIO Sides With the Facility
Losing the QIO review is not the end. Medicare provides several further appeal levels, each slower than the last:
- Redetermination by the Medicare Administrative Contractor that processed the claim.
- Reconsideration by a Qualified Independent Contractor, which you have 180 days to request after an unfavorable redetermination.7Centers for Medicare & Medicaid Services. Second Level of Appeal Reconsideration by a Qualified Independent Contractor
- A hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals, available in 2026 if at least $200 is in dispute.8Federal Register. Medicare Appeals Adjustment to the Amount in Controversy Threshold Amounts for 2026
- Review by the Medicare Appeals Council within HHS.9Centers for Medicare & Medicaid Services. Third Level of Appeal Decision by Office of Medicare Hearings and Appeals
- Judicial review in federal district court.
The QIO expedited review resolves in days. A federal court case can take years. Most disputes that go beyond the second level involve significant dollar amounts or hard questions about how the maintenance standard applies to a specific diagnosis. If you are considering pursuing an appeal past the QIO, talk to a Medicare-focused attorney or a counselor at your State Health Insurance Assistance Program.
The 100-Day Ceiling
Even if no one ever questions your level of care, Medicare Part A only covers up to 100 days of skilled nursing care per benefit period.10eCFR. 42 CFR 409.61 – General Limitations on Amount of Benefits Days 1 through 20 are fully covered. From day 21 through day 100, you owe a daily coinsurance of $217 for 2026.11Centers for Medicare & Medicaid Services. Medicare Deductible, Coinsurance and Premium Rates CY 2026 Update After day 100, federal coverage for that stay ends entirely. Most people never approach 100 days; the level-of-care determination almost always ends coverage first.
If You Have a Medicare Advantage Plan
The framework above describes Original Medicare. If you are enrolled in a Medicare Advantage plan, the broad structure is similar, but the details shift. Many plans require prior authorization before admitting you to a skilled nursing facility, and the plan’s own medical reviewers make the skilled-care call.
When a Medicare Advantage plan terminates coverage, you still get a Notice of Medicare Non-Coverage and can still request an expedited BFCC-QIO review. A timely QIO appeal bypasses the plan’s internal reconsideration and goes straight to an independent reviewer.12Centers for Medicare & Medicaid Services. Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) Review Miss that deadline and the appeal has to run through the plan first. As of 2025, Medicare Advantage enrollees have 65 calendar days from the notice date to submit a plan-level appeal.13Centers for Medicare & Medicaid Services. Medicare Managed Care Appeals and Grievances Cost-sharing, networks, and authorization rules vary widely, so check your plan documents or call the number on your card.
What It Costs If Coverage Really Ends
If coverage ends and you stay, you pay the private rate. National averages for nursing facility care run roughly $300 or more per day for a semi-private room, with private rooms costing more. Regional variation is significant, and the first bill is often a shock.
The facility still cannot simply push you out the door. Federal regulations require skilled nursing facilities to build a discharge plan for every resident, in consultation with the resident and family, that identifies post-discharge needs and arranges the transition to the next setting of care.14eCFR. 42 CFR 483.21 – Comprehensive Person-Centered Care Planning The plan has to account for whether caregivers at home can realistically manage the patient’s needs, and the facility must provide a list of available home health agencies, other nursing facilities, or rehabilitation centers.
For patients who need ongoing facility care and cannot pay private rates, Medicaid is usually the next step. Medicaid covers long-term nursing home stays, but eligibility rules are strict, thresholds vary by state, and state Medicaid agencies review asset transfers going back several years. An elder law attorney or your state Medicaid office can walk you through the specifics before you make financial moves you cannot reverse.