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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 patients 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, Publication 100-02, 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, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. 
 
The rules state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new 
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the 
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under 
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The 
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character 
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-
mix group. The fifth character represents the assessment indicator code.  
 You can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules say that active diagnoses are intended to code diseases that have a direct relationship to the residents 
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or 
risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to generate an 
updated, accurate picture of the residents current health status. You can find this rule in the Centers for 
Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 
3. 
 
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.