CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) coverage criteria

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Defines eligibility criteria and the intake/provider form process for members seeking Special Supplemental Benefits for the Chronically Ill (SSBCI); applies to Anthem/Anthem Blue Cross Medicare members completing the form and providers certifying eligibility.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed SSBCI form by fax (800-833-8554), secure online account (www.anthem.com/ca), or mail to P.O. Box 659403, San Antonio, TX 78265-9714; providers must attest the patient meets qualifying criteria and sign the Provider Information section.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to submit

12lookback period (months)

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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 change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to submit

12lookback period (months)

SSBCI Coverage Criteria

SSBCI eligibility criteria

Covered when ALL of the following are met:

Core eligibility: Member has one of the eligible chronic conditions listed in the form AND the condition is life-threatening or significantly limits overall health or function, has a high risk of hospitalization or other adverse health outcomes, AND requires intensive care coordination.

Condition list appears in chunks 4-5.

Demonstration of need (one or more): 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 (including primary care or specialty care) 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 need for one or more outpatient durable medical equipment items (examples listed).12 months for visit-based criteria

DME examples include group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2/3 mattresses.

The form does not list any explicit exclusions. It instead provides an extensive list of eligible chronic conditions and notes that enrollment in Anthem Blue Cross depends on contract renewal and plan specifics. Providers should therefore confirm member eligibility under the member’s specific contract or plan benefits before assuming coverage for SSBCI services.

Coding & Lookback Rules

Pre-diabetes laboratory thresholds

Fasting blood glucose100-125 mg/dL

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Condition labelPre-diabetes (listed under Diabetes mellitus)

Utilization lookback period for qualifying visits

Utilization lookback period (visit-based criteria)12 months

Applies toInpatient admissions, urgent care/ED visits, and outpatient visits related to the chronic condition

Threshold for outpatient visitsTwo or more outpatient visits in the last 12 months

Form Submission & Provider Responsibilities

Note

Form submission requirement

Submit the completed form by faxing it to 800-833-8554, uploading it to your secure online account at www.anthem.com/ca, or mailing it to P.O. Box 659403, San Antonio, TX 78265-9714. Incomplete sections or failure to submit the Provider Information and signature may prevent processing.

Fax: 800-833-8554
Upload: www.anthem.com/ca (secure online account)
Mail: P.O. Box 659403, San Antonio, TX 78265-9714

Documentation Required

Provider action required

Fill out the Member Information section, then take the form to the healthcare provider to complete the Provider Information section. The provider must complete all Provider Information fields and certify eligibility.

Provider must complete: first and last name, street address, city, state, ZIP, phone, fax, NPI
Provider must sign and date the certification statement

Definitions & Demonstration of Need

Qualifying demonstration of need

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

Urgent care / Emergency 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 (including primary or specialty care) related to the chronic condition in the last 12 months

Other demonstrations of needRequirement for home health visits, impairment in activities of daily living or cognitive impairment, or need for one or more outpatient DME related to the chronic condition

Background

The Special Supplemental Benefits for the Chronically Ill (SSBCI) are intended for Medicare beneficiaries with chronic conditions that are life‑threatening or significantly limit overall health or function, have a high risk of hospitalization or other adverse outcomes, and require intensive care coordination. The policy’s eligibility framework requires (1) the member have one of the eligible chronic conditions listed on the form and (2) demonstration of need through utilization, functional impairment, home‑health needs, or outpatient durable medical equipment requirements (visit‑based criteria use a 12‑month lookback period). The form lists dozens of qualifying conditions (examples include cardiovascular disease, diabetes and pre‑diabetes, chronic lung disorders, neurologic disorders, severe hematologic disorders, HIV/AIDS, and chronic mental health conditions) and specifies examples of qualifying needs such as inpatient admissions, ED/urgent care visits, multiple outpatient visits, home health visits, impairment in activities of daily living, cognitive impairment, or need for specified outpatient DME.