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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 Home Health Aide (HHA) services may be covered only if the enrollee needs one or more of the following qualified skilled services: 1. Skilled nursing care; 2. Physical therapy; 3. Occupational therapy; or 4. Speech pathology services. HHA services are no longer covered for enrollees once the qualifying skilled service has ended. To be covered, home health aide services must be reasonable and necessary. You can find this rule at 42 CFR Sections 409.44 and 409.45. The rules say that medical social services that are provided by a qualified medical social worker or a social work assistant under the supervision of a qualified medical social worker may be covered as home health services where the beneficiary meets the qualifying criteria, and: 1. The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient's medical condition or rate of recovery; and, 2. The plan of care indicates how the services which are required necessitate the skills of a qualified social worker or a social work assistant under the supervision of a qualified medical social worker to be performed safely and effectively. You can find this rule in the Medicare Benefit Policy Manual, Chapter 7, Home Health Services - Section 50.3 - Medical Social Services. The rules say that where both of these requirements are met, services of these professionals which may be covered include, but are not limited to: 1. Assessment of the social and emotional factors related to the patient's illness, need for care, response to treatment and adjustment to care; 2. Assessment of the relationship of the patient's medical and nursing requirements to the patient's home situation, financial resources and availability of community resources; 3. .Appropriate action to obtain available community resources to assist in resolving the patient's problem (NOTE: Medicare does not cover the services of a medical social worker to complete or assist in the completion of an application for Medicaid because Federal regulations require the State to provide assistance in completing the application to anyone who chooses to apply for Medicaid.); 4. Counseling services that are required by the patient; and 5. Medical social services furnished to the patient's family member or caregiver on a short-term basis when the HHA can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patient's medical condition or to the patient's rate of recovery. To be considered "clear and direct," the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient's medical treatment or rate of recovery. Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long-term social services furnished to family members, such as ongoing alcohol counseling, are not covered.
You can find this rule in the Medicare Benefit Policy Manual, Chapter 7, Home Health Services - Section 50.3 - Medical Social 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.