CurrentBlue Cross Blue Shield - MainePolicy N/A

Provider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)

Form and clinical criteria used by providers to confirm Medicare Advantage members meet CMS eligibility for Special Supplemental Benefits for the Chronically Ill (SSBCI). Applies to providers submitting eligibility confirmation to AMH Health, LLC for MaineHealth members requesting SSBCI benefits.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProvider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the provider confirmation form attesting whether the member meets the defined SSBCI criteria and submit it by fax or the online/QR code instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Form pages

1Fax submission endpoint

~60Listed eligible chronic conditions (approx.)

SSBCI eligibility confirmation — clinical criteria

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ALL of the following

Member has one of the eligible chronic conditions listed in this form
Condition is life-threatening or significantly limits overall health or function
Condition has a high risk of hospitalization or other adverse health outcomes
Condition requires intensive care coordination
Demonstrated by one or more of the following
- One or more inpatient admissions (including behavioral health) related to the chronic condition in the last 12 months
- One or more urgent care or emergency room visits related to the chronic condition in the last 12 months
- Two or more outpatient visits related to the chronic condition (including primary care or specialty care visits) in the last 12 months
- Patient requires home health visits related to the chronic condition
- Patient has impairment in activities of daily living (bathing, dressing, toileting, transferring, eating) or cognitive impairments related to the chronic condition
- Patient has a need for one or more durable medical equipment (DME) in the outpatient setting (examples listed)

Listed eligible chronic conditions and example DME

Eligible chronic conditions:

• Chronic alcohol use disorder and other substance use disorders

• Autoimmune disorders (polyarteritis nodosa; polymyalgia rheumatica; polymyositis; dermatomyositis; rheumatoid arthritis; systemic lupus erythematosus; psoriatic arthritis; scleroderma)

• Cancer

• Cardiovascular disorders (cardiac arrhythmias; coronary artery disease; peripheral vascular disease; valvular heart disease; chronic heart failure)

• Dementia

• Diabetes mellitus (includes prediabetes as defined)

• Overweight, obesity, metabolic syndrome

• Chronic gastrointestinal disease (chronic liver disease; NAFLD; hepatitis B; hepatitis C; pancreatitis; IBS; IBD)

• Chronic kidney disease (CKD requiring dialysis/ESRD; CKD not requiring dialysis)

• Severe hematologic disorders (aplastic anemia; hemophilia; ITP; myelodysplastic syndrome; sickle-cell disease excluding trait)

• Chronic venous thromboembolic disorder

• HIV/AIDS

• Chronic lung disorders (asthma; chronic bronchitis; cystic fibrosis; emphysema; pulmonary fibrosis; pulmonary hypertension; COPD)

• Chronic and disabling mental health conditions (bipolar disorder; major depressive disorder; paranoid disorder; schizophrenia; schizoaffective disorder; PTSD; eating disorders; anxiety disorders)

• Neurologic disorders (ALS; cerebral palsy; epilepsy; extensive paralysis; Huntington's disease; multiple sclerosis; Parkinson's disease; polyneuropathy; fibromyalgia; chronic fatigue syndrome; spinal cord injuries; spinal stenosis; stroke-related neurologic deficit; traumatic brain injury; stroke)

• Post-organ transplantation care

• Immunodeficiency and immunosuppressive disorders

• Conditions that cause cognitive impairment (Alzheimer's disease; intellectual and developmental disabilities; traumatic brain injuries; disabling mental illness with cognitive impairment; mild cognitive impairment)

• Conditions causing similar functional challenges (limb loss; paralysis; arthritis; chronic back pain; conditions impairing vision/hearing/taste/touch/smell; conditions requiring continued therapy services)

• Other listed conditions (hypertension; osteoporosis)

Examples of outpatient DME that may indicate need:

• Group 3 power/manual wheelchair

• Noninvasive ventilation (NIV)

• Wound vacuums

• BiPAP machines

• Mechanical in-exsufflation devices

• Group 2 or group 3 mattresses

Purpose and clinical context

This form operationalizes CMS guidance for Special Supplemental Benefits for the Chronically Ill (SSBCI) by requiring a provider's attestation that a Medicare Advantage enrollee has a qualifying chronic condition that meets the defined severity and utilization or functional criteria.

Providers must complete and sign the confirmation form certifying whether the member meets the defined SSBCI criteria and submit the completed form by fax to 877-660-8362 (or via the AMH Health online form/QR code per instructions).

The form summarizes the eligible chronic conditions and provides examples of outpatient durable medical equipment (DME) — such as power/manual wheelchairs, noninvasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, and specialized mattresses — which can demonstrate the member's need when establishing eligibility under CMS requirements.

OpenPayer

Provider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)

SSBCI eligibility confirmation — clinical criteria

Listed eligible chronic conditions and example DME

Required provider actions for submission

Purpose and clinical context

Defined terms

Policy update changes

Provider Confirmation: Special Supplemental Benefits for the Chronically Ill (SSBCI)

SSBCI eligibility confirmation — clinical criteria

Listed eligible chronic conditions and example DME

Required provider actions for submission

Purpose and clinical context

Defined terms

Policy update changes

Other policies to review