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Decision: unknown

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 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 Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
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. The Plan 
contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. These additional benefits include $160 
allowance every 3 months for healthy food purchases and/or electricity, water, and/or phone bill payments, 
transportation for non-medical needs, and home assistance services such as repairs. To be eligible for these 
additional benefits, you must meet the following requirements: You must have one or more comorbid and 
medically complex chronic conditions that are life-threatening or significantly limit your health or general 
functioning (see the list of applicable conditions below). In addition, you must have a high risk of 
hospitalization and other adverse health outcomes; and must require intensive care coordination. The eligible 
chronic conditions are: 
1. Chronic alcohol and other drug dependence; 
2. Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis, 
Rheumatoid arthritis, and Systemic lupus erythematosus; 
3. Cancer, excluding pre-cancer conditions or in-situ status; 
4. Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular 
disease, and Chronic venous thromboembolic disorder; 
5. Chronic heart failure; 
6. Dementia; 
7. Diabetes mellitus; 
8. End-stage liver disease; 
9. End-stage renal disease (ESRD) requiring dialysis; 
10. Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic 
purpura, Myelodysplastic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic 
venous thromboembolic disorder; 
11. HIV/AIDS; 
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and 
Pulmonary hypertension; 
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive 
disorders, Paranoid disorder, Schizophrenia, and Schizoaffective disorder; 
 
 
14. Neurologic disorders limited to: Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis, 
Huntington's disease, Multiple sclerosis, Parkinson's disease, Polyneuropathy, Spinal stenosis, and 
Stroke-related neurologic deficit; and 
15. Stroke 
 
You can find this information in Chapter 4 on pages 119 to 123 of the Plan's 2020 Evidence of Coverage.