CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

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

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Explains eligibility criteria and the application process for Special Supplemental Benefits for the Chronically Ill (SSBCI) for Anthem/BCBS members and instructs members and providers how to submit the completed form.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

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 ActionProviders must complete and sign the Provider Information section and submit the completed form by fax, online upload, or mail for the member to be evaluated for SSBCI benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60+Eligible conditions (approx.)

12 monthsEvidence window

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CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

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

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Wisconsin policy alerts

Know when Blue Cross Blue Shield - Wisconsin releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

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 ActionProviders must complete and sign the Provider Information section and submit the completed form by fax, online upload, or mail for the member to be evaluated for SSBCI benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60+Eligible conditions (approx.)

12 monthsEvidence window

Coverage criteria for SSBCI

SSBCI eligibility criteria

Covered when ALL of the following are met:

Primary qualifications

Demonstration of need (any one applies): 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 in the last 12 months OR requires home health visits related to the chronic condition OR has impairment in activities of daily living or cognitive impairments related to the chronic condition OR has a chronic condition and needs one or more outpatient durable medical equipment (DME) items (examples include group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or group 3 mattresses).12 months for utilization measures
Examples of qualifying DME are illustrative and not exhaustive.

The SSBCI form does not provide a list of explicit exclusions. Instead, it presents an extensive list of eligible chronic conditions and examples of other conditions that may produce similar functional challenges or needs. The eligible conditions span multiple organ systems and care needs, including cardiovascular, neurologic, pulmonary, metabolic, autoimmune, hematologic, renal, mental health, and conditions that impair cognition or activities of daily living (see eligible condition examples).

Because the form emphasizes which chronic conditions and related functional limitations qualify for Special Supplemental Benefits for the Chronically Ill, absence from the eligible list should not be interpreted as an explicit exclusion on the form itself; the document relies on the enumerated eligible conditions and examples rather than a separate exclusions section.

The form does not identify any specific services or conditions as ‘not medically necessary’. It omits a dedicated list of non‑covered items and instead focuses on documenting qualifying chronic conditions, utilization or functional evidence, and the provider certification needed to evaluate eligibility.

Coding and clinical thresholds

inv-04: Look-back period for utilization

Look-back period12 months

inv-05: Pre-diabetes lab thresholds

Fasting blood glucose100-125 mg/dL

Hemoglobin A1C (Hgb A1C)5.7-6.4%

InterpretationEither fasting blood glucose OR Hgb A1C in these ranges qualifies as pre-diabetes per the policy

What providers must do

Documentation Required

Form completion and provider signature required

Complete the Provider Information section on the SSBCI form and submit the finished form by fax, secure online upload, or mail. The form must include the provider signature and date certifying the patient meets the SSBCI criteria.

Submit completed form by fax to 800-833-8554.
Or upload to member's secure online account at www.anthem.com.
Or mail to P.O. Box 659403, San Antonio, TX 78265-9714.

Step Therapy

No step therapy requirements specified

No step therapy or prior treatment sequence is required or specified on this SSBCI form.

Documentation Required

Definitions and qualifying evidence

inv-11: Qualifying evidence

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

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

Outpatient visitsTwo or more outpatient visits related to the chronic condition (including primary or specialty care) in the last 12 months

Home health needsRequirement for home health visits related to the chronic condition

Functional/cognitive impairmentImpairment in activities of daily living or cognitive impairment related to the chronic condition

Outpatient DME needNeed for one or more outpatient durable medical equipment items related to the chronic condition (examples listed in policy)

Background on SSBCI

Special Supplemental Benefits for the Chronically Ill (SSBCI) are intended to support members with chronic health conditions that are life‑threatening or significantly limit health or function, place members at high risk for hospitalization or other adverse outcomes, and require intensive care coordination. Eligibility is demonstrated by a qualifying chronic condition from the form’s list plus evidence of need such as recent inpatient, emergency/urgent, or outpatient utilization, requirements for home health, impairment in activities of daily living or cognition, or need for outpatient durable medical equipment. The form provides submission instructions and directs providers to complete and sign the Provider Information section and submit the completed form by fax, secure online upload, or mail for evaluation.