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 application process for Medicare members seeking Special Supplemental Benefits for the Chronically Ill (SSBCI); applies to members and providers submitting the SSBCI form to Blue Cross Blue Shield - Wisconsin (Anthem).

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 (with provider signature and NPI) by fax, secure upload, or mail to request consideration for benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

One-page formdocument format

Multipleeligible conditions

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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

Receive email alerts as soon as relevant payer policies are published or updated.

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 (with provider signature and NPI) by fax, secure upload, or mail to request consideration for benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

One-page formdocument format

Multipleeligible conditions

Coverage Criteria for SSBCI

Eligibility criteria for SSBCI

Covered when ALL of the following are met:

Member has an eligible chronic condition: Member must have one of the eligible chronic conditions listed in the form (examples include but are not limited to: cardiovascular disease, chronic lung disorders, diabetes, chronic kidney disease, neurologic disorders, severe hematologic disorders, HIV/AIDS, cancer, chronic mental health conditions, substance use disorders, chronic gastrointestinal disease, post-organ transplant care, conditions causing cognitive or functional impairment).

See full list of eligible conditions in chunks 4-5.

Condition meets SSBCI severity and coordination criteria: 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.

From CMS guidelines summarized on the form (chunk 3).

Demonstration of need (one required): 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 requirement for home health visits related to the chronic condition OR impairment in activities of daily living or cognitive impairment related to the chronic condition OR need for one or more outpatient durable medical equipment (examples listed such as group 3 power/manual wheelchair, non-invasive ventilation, wound VACs, BiPAP, mechanical in-exsufflation devices, group 2/3 mattresses).see text

Listed options appear in chunk 3.

The SSBCI form does not include a separate list of explicit exclusions. Instead, the document presents a list of eligible chronic conditions and examples of qualifying diagnoses; eligibility determination is based on whether the member meets the conditions and severity/need criteria described on the form. See the eligible conditions enumerated on the form for the scope of conditions considered for SSBCI.

The form does not state specific services or conditions that are "not medically necessary." Rather, coverage determinations rely on whether the member meets the listed eligibility criteria and the provider’s attestation on the completed form. Submission and review of the completed Provider Information section is the mechanism used to establish whether the request meets SSBCI criteria.

Coding and Clinical Thresholds

Durable Medical Equipment examplesHCPCS

group 3 power / manual wheelchair	group 3 power / manual wheelchair
non-invasive ventilation (NIV)	non-invasive ventilation (NIV)
wound vacuums	wound vacuums
bipap machines	bipap machines
mechanical in-exsufflation devices	mechanical in-exsufflation devices
group 2 or group 3 mattresses	group 2 or group 3 mattresses

Pre-diabetes lab thresholds

Fasting blood glucose100-125 mg/dl

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Condition labelPre-diabetes (listed under Diabetes mellitus)

Provider Actions & Submission Requirements

Prior Authorization

Form submission (fax, secure upload, or mail)

Submit the completed SSBCI form to request Special Supplemental Benefits for the Chronically Ill. The form must be sent by fax, uploaded to the member's secure online account, or mailed to the address on the form; submission is the mechanism to initiate benefit consideration.

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

Note

Complete all additional provider fields on the form

Complete any additional provider-required fields on the SSBCI form requested by Anthem; ensure all requested clinical and administrative items on the form are filled to support eligibility determination.

Provide clinical details that demonstrate the member meets the qualifying condition criteria (see form examples)

Definitions and Demonstrations of Need

Qualifying demonstrations of need

Inpatient admissionsOne or more inpatient admissions related to the chronic condition in the last 12 months (inclusive of behavioral health)

Urgent care/ER 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 care or specialty) in the last 12 months

Home healthRequirement for home health visits related to the chronic condition

ADL or cognitive impairmentImpairment in activities of daily living (bathing, dressing, toileting, transferring, eating) or cognitive impairments related to the chronic condition

Outpatient DME examplesNeed for outpatient durable medical equipment such as group 3 power/manual wheelchair, non-invasive ventilation (NIV), wound vacuums, BiPAP machines, mechanical in-exsufflation devices, or group 2/3 mattresses

Background

The SSBCI benefit is intended to support Medicare members with chronic health conditions that are life‑threatening or substantially limit health and function, carry a high risk of hospitalization or adverse outcomes, and require intensive care coordination. The form is used to document member eligibility and to request consideration of Special Supplemental Benefits for the Chronically Ill for those members who meet the stated clinical and utilization/functional criteria.