CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

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

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Form and criteria for members to apply for Special Supplemental Benefits for the Chronically Ill (SSBCI); governs eligibility assessment and submission process for Medicare beneficiaries covered by the payer. Affects members with chronic conditions and providers completing the provider section.

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 ActionSubmit the completed SSBCI form (including provider certification and signature) by fax, secure online upload, or mail for benefit consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page/form provided

6+eligible condition categories

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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 ActionSubmit the completed SSBCI form (including provider certification and signature) by fax, secure online upload, or mail for benefit consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page/form provided

6+eligible condition categories

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

SSBCI Eligibility Criteria

Covered when ALL of the following are met

Member has eligible chronic condition: Member must have one of the listed eligible chronic conditions (see Eligible conditions list).

Eligible conditions listed in source chunks 4-5

Condition severity / impact: 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.

Per CMS guidelines on the form (see chunk 3)

Demonstrated need (one or more required): Evidence must include one or more of: one or more inpatient admissions 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 in the last 12 months (including primary or specialty care); requirement for home health visits related to the chronic condition; impairment in activities of daily living related to the chronic condition or cognitive impairments; or need for one or more specified outpatient durable medical equipment (including but not limited to group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or 3 mattresses).see text

List of acceptable evidence provided on the form (chunk 3)

The form does not list explicit exclusions. Instead, it provides a broad, non‑exhaustive list of eligible chronic conditions and also notes conditions that may cause similar functional challenges or require similar services. The eligible condition lists span multiple disease categories (e.g., autoimmune disorders, cardiovascular disorders, diabetes, chronic kidney disease, chronic lung disorders, neurologic disorders, chronic and disabling mental health conditions, cancer, HIV/AIDS, and others) and include specific examples such as ALS, Parkinson’s disease, multiple sclerosis, chronic heart failure, COPD, and dementia.

Because the form focuses on conditions that produce significant functional limitation or increased risk of hospitalization, providers should rely on the listed eligible conditions and the accompanying demonstration-of-need criteria rather than expecting an explicit exclusion list to define ineligibility.

Relevant Clinical Thresholds and Coding

Pre-diabetes lab thresholds

Fasting blood glucose100-125 mg/dl

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Condition contextThis threshold applies to pre-diabetes listed under Diabetes mellitus in eligible conditions

Form Submission and Provider Requirements

Note

Submission Requirement

Submit the completed form by faxing it to 800-833-8554, uploading it to your secure online account at www.anthem.com, or mailing it to P.O. Box 659403, San Antonio, TX 78265-9714. Submission via one of these methods is required for processing.

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

Documentation Required

Required Form Fields

Completed Member Information and Provider Information sections must be provided. 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, street address, city, state, ZIP, phone number, fax number, and NPI.

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

Qualifying Evidence and Definitions

Evidence demonstrating need (acceptable items)

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

Multiple outpatient visitsTwo or more outpatient visits related to the chronic condition in the last 12 months

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

Impairment in ADLs or cognitionImpairment in daily living activities (bathing, dressing, toileting, transferring, eating) or cognitive impairments related to the chronic condition

Outpatient DME needNeed for one or more specified outpatient durable medical equipment (examples: group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP, mechanical in-exsufflation devices, group 2 or 3 mattresses)

Policy Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) are intended for members with chronic conditions that are life‑threatening or significantly limit overall health or function, place the member at high risk of hospitalization or adverse outcomes, and require intensive care coordination. Eligibility is established by documenting one of the listed qualifying chronic conditions plus evidence of need such as recent inpatient admissions, emergency or urgent care visits, multiple outpatient visits, requirement for home health, impairment in activities of daily living or cognitive impairment, or the need for specified outpatient durable medical equipment.