The Centers for Medicare and Medicaid Services (CMS) issued revised Notice of Medicare Non-Coverage (NOMNCs) and Detailed  Explanation of Non-Coverage (DENC) forms in November 2024 to align with finalized changes to the Medicare Advantage (MA) regulations that took effect January 1, 2025. The updated forms reflect additional protections for MA enrollees that were finalized as part of the CY2025 MA policy and technical rule (CMS-4205-F).

The two regulatory changes necessitating the forms’ update include:

1. Aligning MA enrollees’ appeal rights with traditional Medicare policies on expedited appeals conducted by independent review entities (IREs). Previously, MA enrollees receiving skilled nursing facility (SNF) services, home health agencies (HHAs) and Comprehensive Outpatient Rehabilitation Facility (CORFs) services did not have the same protections that traditional Medicare beneficiaries had. The updated regulation now permits MA enrollees to receive an expedited appeal by an IRE (sometimes also referred to as to the Beneficiary and Family Centered Care Quality and Improvement Organization (BFCC-QIO) ) even if they don’t submit the appeal request timely (typically by noon the day before coverage is scheduled to terminate). Previously, untimely appeals were returned to the MA organization for review.
2. Reinstating MA enrollee’s right to appeal last day of coverage decisions even if they leave the care of a SNF, HHA or CORF. Previously, if services were terminated (usually because the person wouldn’t be able to pay for the care/services if the appeal did not go in their favor), the person could not appeal the decision.

Links to the updates NOMNC (CMS-10123) can be found here.

While the NOMNC informs beneficiaries on how to request an expedited determination from their BFCC-QIO and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO, a Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination.  The DENC explains the specific reasons for the end of covered services.

In addition, the CY2025 regulation also changed the DENC by adding a new element that health plans must complete. This new provision provides special instructions to plans related to repeat appeals within the same period of care. In cases where an enrollee has received a favorable appeal decision from the BFCC-QIO, plans must now identify the “specific change in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.”

This change has the potential to slow down the reissuance of NOMNCs by MA plans after an enrollee’s successful appeal of a coverage termination. LeadingAge members have noted examples where an enrollee has had to appeal as many as 9 times because NOMNCs are reissued within 1-2 days of a successful appeal. Though not required, providers would be encouraged to ensure the new DENC section is completed by the plan following an enrollee’s successful appeal prior to issuing it to the enrollee. Plans are to implement the revised notices “as soon as practicable, but no later than April 1, 2025.” This applies to the DENC issued by MA plans or PDPs. Here is the link to DENC form.