CurrentAnthemPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) — Coverage Criteria

Defines eligibility criteria, qualifying chronic conditions, and submission instructions for members seeking Special Supplemental Benefits for the Chronically Ill (SSBCI) under Anthem's Medicare-related benefit offering. Applies to Anthem members in North Carolina completing the SSBCI attestation form and providers certifying eligibility.

Policy Summary

PayerAnthem

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed member and provider attestation form by fax, secure upload, or mail to enroll the member for SSBCI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1member/provider attestation form

>=1eligible chronic conditions listed

12lookback period (months)

yesADL impairment considered

Coverage and Eligibility Criteria

Policy Summary

PayerAnthem

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed member and provider attestation form by fax, secure upload, or mail to enroll the member for SSBCI.

SourceLink

On This Page

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Member eligibility prerequisites

Evidence of recent utilization or impairment: Must demonstrate one or more of: one or more inpatient admissions related to the chronic condition in the last 12 months; OR one or more urgent care or emergency room visits related to the chronic condition in the last 12 months; OR two or more outpatient visits related to the chronic condition (including primary care or specialty care) in the last 12 months; OR requires home health visits related to the chronic condition; OR has impairment in activities of daily living (bathing, dressing, toileting, transferring, eating) or cognitive impairments related to the chronic condition; OR has a need for one or more outpatient durable medical equipment (DME) items listed (examples: group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or 3 mattresses).12 months for visit-based criteria
DME examples and ADL items are taken from the form.

Coding and Lookback Period

No billing codes providedmixed

No codes listed

Lookback period — 12 months for prior admissions/visits

Lookback period12 months (used to assess prior inpatient admissions, urgent care/ER visits, or outpatient visit counts related to the chronic condition)

Applies to visit-based criteriaOne or more inpatient admissions, one or more urgent care/ER visits, or two or more outpatient visits must occur within the 12-month lookback period

Source guidancePer CMS-based SSBCI form criteria, the 12-month period is the timeframe for demonstrating recent utilization or impairment related to the chronic condition

Pre-diabetes lab thresholds — fasting glucose and HbA1c ranges

Fasting blood glucose100-125 mg/dL

Hemoglobin A1c (Hgb A1C)5.7-6.4%

Condition identifiedPre-diabetes is listed under eligible chronic conditions with these laboratory thresholds

Submission, Attestation, and Provider Responsibilities

Note

Submission for SSBCI enrollment

If you have a chronic health condition and believe the member qualifies for Special Supplemental Benefits for the Chronically Ill (SSBCI), submit the completed SSBCI enrollment form by one of the following routes: fax to 800-833-8554, upload to the member's secure online account at www.anthem.com/ca, or mail to P.O. Box 659403, San Antonio, TX 78265-9714. No prior authorization codes are listed on this form.

Fax: 800-833-8554
Secure upload: www.anthem.com/ca
Mail: P.O. Box 659403, San Antonio, TX 78265-9714

Documentation Required

Provider responsibilities and attestation

Providers must complete the Provider Information section and sign the attestation certifying the patient meets the defined SSBCI criteria before submission. Ensure all provider contact fields (address, phone, fax, and NPI) are completed.

Complete provider name, address, phone, fax, and NPI
Sign and date the attestation statement

Documentation Required

Required form fields and provider attestation

The form requires completed Member Information and Provider Information sections. Member Information must include member first and last name, date of birth, Medicare beneficiary ID, and Member ID. Provider Information must include provider first and last name, full practice address, phone, fax, NPI, a signed attestation statement, and the signature date.

Member Information: first name, last name, date of birth, Medicare beneficiary ID, Member ID
Provider Information: provider name, street address, city, state, ZIP, phone, fax, NPI, signature, date

Denial Risk

Submission requirement

Incomplete submissions or using an incorrect submission route may result in processing delays or denial of the SSBCI enrollment request. Verify all required fields are filled and that the provider attestation is signed and dated before sending.

Incomplete or unsigned forms may be delayed or denied
Use only fax, secure upload, or mail as listed — do not email unsecured documents

Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) are intended for Medicare beneficiaries who have one of the listed chronic conditions and whose condition is either life‑threatening or significantly limits overall health or function, places them at high risk of hospitalization or other adverse health outcomes, and requires intensive care coordination. Eligibility additionally requires demonstration of recent healthcare utilization or functional impairment related to the chronic condition (for example: inpatient admission, urgent care/ER visit, or multiple outpatient visits within the 12‑month lookback period, home health visits, impairment in activities of daily living, cognitive impairment, or need for outpatient DME).

Key Definitions

Demonstrated need — inpatient/ER/outpatient visit thresholds within 12 months

Inpatient admissionsOne or more inpatient admissions related to the chronic condition in the last 12 months

Urgent care / ER visitsOne or more urgent care or emergency room visits related to the chronic condition in the last 12 months

Outpatient visit countTwo or more outpatient visits related to the chronic condition in the last 12 months (includes primary care or specialty care)

Other evidence of needHome health visits, impairment in activities of daily living or cognitive impairments, or need for outpatient DME also satisfy demonstrated need criteria

Intensive care coordination — definition noting high risk of hospitalization and ongoing management needs

DefinitionCare needs that place the member at high risk of hospitalization or other adverse outcomes and require ongoing management across settings

ContextThis definition is based on CMS SSBCI guidance requiring the condition to be life-threatening or significantly limit health/function and require intensive care coordination

Implication for providersMember must have one of the eligible chronic conditions plus documented evidence (utilization, ADL impairment, DME, or home health) showing need for ongoing cross-setting management