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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met: 1. The patient requires skilled nursing or skilled rehabilitation services; 2. The patient requires these services on a daily basis; 3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 8, Section 30. The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110. When a hospital is providing extended care services, it will be treated as a SNF for purposes of applying coverage rules. This means that services provided in the swing bed are subject to the same Part A coverage, deductible, coinsurance and physician certification/recertification provisions that are applicable to SNF extended care services. The SNF coverage provisions are set forth in 42 CFR 409 Subpart D and are more fully explained in this chapter. A patient in a swing bed cannot simultaneously receive coverage for both SNF-level services under Part A and inpatient hospital ancillary services under Part B. Swing bed patients who no longer qualify for Part A coverage of SNF-level services under the Medicare program (due to exhaustion of Part A SNF benefits, dropping below a SNF level of care, etc.) revert to receipt of a hospital level of care in the swing bed (see the Medicare Benefit Policy Manual, Chapter 6, "Hospital Services Covered Under Part B," 10). Thus, any further Medicare coverage in the swing bed would be for inpatient hospital ancillary services under Part B, notwithstanding a patient's eligibility for Medicaid NF coverage.
You can find this information in Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance,10.3 - Hospital Providers of Extended Care Services.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.