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What is SSBCI (Special Supplemental Benefits for the Chronically Ill)?

SSBCI are benefits that can be offered to Medicare Advantage members with one or more complex chronic conditions, who are at high risk for hospitalization or adverse health outcomes, and who require intensive care coordination. These benefits are in addition to the benefits that traditional Medicare covers, and can include non-primarily health related benefits so long as there is a reasonable expectation of improving or maintaining the health or overall function of the member.

Special Supplemental Benefits for Chronically Ill Enrollees (SSBCI) Eligibility Criteria

  • Determination of eligibility for the SSBCI
    • Documentation must include that the member has completed a Health Risk Assessment and
    • Has one or more complex chronic conditions including:
      • Cardiovascular disorders limited to:
        • Cardiac arrhythmias
        • coronary artery disease
        • Peripheral vascular disease
        • Chronic venous thromboembolic disorder
      • Chronic heart failure
      • Chronic and disabling mental health conditions limited to:
        • Bipolar disorders
        • Major depressive disorders
        • Paranoid disorder
        • Schizophrenia
        • Schizoaffective disorder
      • Chronic lung disorders limited to:
        • Asthma
        • Chronic bronchitis
        • Emphysema
        • Pulmonary fibrosis
        • Pulmonary hypertension
      • Dementia
      • Diabetes
      • End-stage liver disease
      • End-stage renal disease (ESRD)
      • HIV/AIDS
      • Neurologic disorders limited to:
        • Amyotrophic lateral sclerosis (ALS)
        • Epilepsy
        • Extensive paralysis such as:
          • Hemiplegia
          • Quadriplegia
          • Paraplegia
          • Monoplegia
        • Huntington’s disease
        • Multiple sclerosis
        • Parkinson’s disease
        • Polyneuropathy
        • Spinal stenosis
        • Stroke-related neurologic deficit
      • Stroke
    • The member is at high-risk for hospitalization or adverse health outcomes. UM Coordinator will request records from Primary Care Provider (PCP) to verify chronic condition(s).
    • The member is participating in the case management program:
      • C-SNP case management as defined in the Model of Care
      • Non – C-SNP case management, including:
        • The member receives a copy of their SSBCI care plan, and the case manager follows up as needed throughout the year.
  • The UM Coordinator will proceed with processing the SSBCI request following the SSBCI Request Workflow.