Special Supplemental Benefits for the Chronically Ill (SSBCI) Eligibility Information

 

On some Medicare Advantage plans, the Health Plan offers SSBCI benefits to eligible members. These benefits are designed to help members with complex chronic conditions maintain or improve their overall health, and are offered in accordance with Medicare regulations under 42 CFR 422.102(f). Not all plans offer SSBCI benefits; check your Evidence of Coverage or contact us for the specifics for your plan.

 

How The Health Plan Determines Eligibility

To qualify for SSBCI, members must meet certain criteria in order to meet the regulatory definition of a chronically ill enrollee.

A member must ave one or more medically complex chronic conditions which meet all three of these criteria:

1. The chronic condition/conditions are life threatening or significantly limit overall health or functioning
2. The chronic condition/conditions leave the member at high risk for hospitalization and/or other adverse health outcomes
3. The chronic condition/conditions result in the member requiring intensive care coordination and support to manage their overall health

When relying on clinical and claims data to determine member eligibility for SSBCI benefits, THP uses the following objective clinical criteria, requiring that members meet at least one of these criteria under both “High Risk of Hospitalization or Adverse Health Outcomes” and “Requires Intensive Care Coordination”:

1. 1. High Risk of Hospitalization or Adverse Health Outcomes:
      1. Hospital admission, ED visit, or observation stay within the past 24 months related to the chronic condition
      2. 2 or more outpatient/specialist visits related to the chronic condition within the past 12 months
      3. Uncontrolled clinical indicators demonstrating difficulty maintaining condition control within the past 12 months  (e.g. elevated A1c, unstable blood pressure, advancement of disease stages, adjustment or change in prescriptions for condition management, or any other documented medication change or disease exacerbation indicator)
      4. Taking 3 or more daily maintenance prescription medications,  5 or more ongoing prescription medications total, or any number of multiple prescription medications that carry the risk of drug or condition interactions
      5. Documented difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)
   2. Requires Intensive Care Coordination:
      1. Active participation in a care management program, disease management program, medication therapy management program
      2. Care coordination across 2 or more specialist providers, care settings, or community resources
      3. Documented history of fall risk, cognitive or social barriers affecting medication adherence or adherence to provider disease management recommendations, or living alone with health related barriers or limitations
      4. Treating provider attestation that the member requires ongoing coordination to handle health and/or social/community needs

Qualifying Conditions

For plans with SSBCI benefits, in 2027 the list of eligible chronic conditions is as follows:

• Cardiovascular disorders
• Chronic heart failure
• Diabetes mellitus
• Chronic alcohol use disorder and other substance use disorders (SUDs)
• Autoimmune disorders
• Cancer
• Dementia
• Overweight, obesity, and metabolic syndrome
• Chronic gastrointestinal disease
• Chronic kidney disease (CKD)
• Severe hematologic disorders
• HIV/AIDS
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Neurologic disorders
• Stroke
• Post-organ transplantation
• Immunodeficiency and immunosuppressive disorders
• Conditions associated with cognitive impairment
• Conditions with functional challenges
• Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell
• Conditions that require continued therapy services in order for individuals to maintain or retain functioning.

How to Request SSBCI Benefits

If your plan offers SSBCI benefits and you feel you may be eligible, ask your provider to fill out The Health Plan’s SSBCI Provider Verification Form.

Once the required information is received, within 60 days The Health Plan will issue you a written notice regarding your eligibility:

• If you are eligible, you will receive instructions on how to access and use your SSBCI benefits.
• If you are not eligible and your request for SSBCI benefits is denied, you will receive a denial notice detailing the decision and informing you of your appeal rights under Medicare Advantage rules.

Additional Information and Disclaimers

The Health Plan applies SSBCI criteria uniformly to all members without discrimination. Specific benefit offerings, limitations, allowances, frequency, etc. are defined annually in your plan’s Evidence of Coverage. All SSBCI offerings are supported by contemporary and relevant clinical literature demonstrating a reasonable expectation that the benefits will help members maintain or improve their general health and function.