CurrentEmpire BluecrossPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Defines eligibility criteria and enrollment instructions for Medicare members seeking Special Supplemental Benefits for the Chronically Ill (SSBCI); affects members with chronic conditions and providers who must certify eligibility.

Policy Summary

PayerEmpire Bluecross

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed SSBCI enrollment form (member and provider sections) by fax, secure upload, or mail to request benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to submit (single SSBCI form)

12lookback period (months)

dozenslisted eligible chronic conditions

fax/upload/mailsubmission methods

Coverage Criteria — SSBCI Eligibility

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Core eligibility: Member has one of the listed eligible chronic conditions and the condition meets all three CMS-guideline impact criteria: (1) is life-threatening or significantly limits overall health or function, (2) has a high risk of hospitalization or other adverse health outcomes, and (3) requires intensive care coordination.

Source: SSBCI qualifying conditions section

Demonstration of need

A: One or more inpatient admissions (inclusive of behavioral health) related to the chronic condition in the last 12 months.
B: One or more urgent care or emergency room visits related to the chronic condition in the last 12 months.
C: Two or more outpatient visits related to the chronic condition (including primary care or specialty care visits) in the last 12 months.
D: Requirement for home health visits related to the chronic condition.
E: Impairment in activities of daily living (bathing, dressing, toileting, transferring, and eating) or cognitive impairments related to the chronic condition.
F: Need for one or more durable medical equipment (DME) items in the outpatient setting related to the chronic condition (including but not limited to group 3 power/manual wheelchair, non-invasive ventilation, wound vacuums, BiPAP machines, mechanical in-exsufflation devices, group 2 or group 3 mattresses).

ref

title": "Eligibility criteria for SSBCI

The SSBCI enrollment form lists numerous eligible chronic conditions that may qualify a member for Special Supplemental Benefits for the Chronically Ill; examples include autoimmune disorders, cancer, cardiovascular disorders, dementia, diabetes (including pre-diabetes), chronic kidney and liver disease, severe hematologic disorders, HIV/AIDS, chronic lung disorders, chronic and disabling mental health conditions, and a broad range of neurologic and musculoskeletal conditions (see full list on the form). The document enumerates eligible conditions but does not provide a separate list of explicitly excluded conditions.

The policy document and SSBCI enrollment form do not contain any explicit statements labeling specific conditions or situations as not medically necessary. The form focuses on listing qualifying chronic conditions and the criteria for demonstrating need without enumerating conditions that are excluded as not medically necessary.

Coding & Clinical Thresholds

inv-04: Lookback period for utilization

Lookback periodAdmissions, urgent care/ED visits, or outpatient visits within the last 12 months

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

Urgent care/ED 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 in the last 12 months (including primary or specialty care)

inv-05: Pre-diabetes lab thresholds

Fasting blood glucose100-125 mg/dl

Hemoglobin A1C (Hgb A1C)5.7-6.4%

Pre-diabetes criteria (either)Member meets pre-diabetes lab thresholds if fasting blood glucose is 100-125 mg/dl OR Hgb A1C is 5.7-6.4%

Provider Submission & Documentation Requirements

Prior Authorization

Submission requirement — completed SSBCI enrollment form signed by provider

Completed SSBCI enrollment form signed by the provider must be submitted to Empire Bluecross by one of the following methods: fax to 800-833-8554; secure upload to the member's online account at www.anthem.com; or mail to P.O. Box 659403, San Antonio, TX 78265-9714.

Fax: 800-833-8554
Secure upload: www.anthem.com (member online account)
Mail: P.O. Box 659403, San Antonio, TX 78265-9714

Note

Provider action required

Provider must complete the Provider Information section of the SSBCI form and sign the certification statement attesting the patient meets the defined criteria for SSBCI.

Documentation Required

Required form fields — member and provider information required on the completed form

The completed form must include both Member Information and Provider Information fields. Member fields: member first and last name, date of birth, Medicare beneficiary ID, Member ID. Provider fields: provider first and last name, street address, city, state, ZIP, phone number, fax number, and NPI.

Member Information required: Member first name, Member last name, Date of birth, Medicare beneficiary ID, Member ID
Provider Information required: Provider first name, Provider last name, Street address, City, State, ZIP, Phone number, Fax number, NPI

Denial Risk

Provider signature required — unsigned/uncertified forms may result in denial of supplemental benefit enrollment

Provider signature and date are required on the Provider Information section. Unsigned or uncertified forms may result in denial of supplemental benefit enrollment.

Background

The purpose of SSBCI is to provide Special Supplemental Benefits to Medicare members who have chronic conditions that are life‑threatening or significantly limit overall health or function, place them at high risk of hospitalization or other adverse outcomes, and require intensive care coordination. The policy targets members who meet these impact criteria and documents qualifying conditions and examples of how need may be demonstrated (for example, recent inpatient admissions, ED/urgent care visits, multiple outpatient visits, requirement for home health, impairment in activities of daily living, cognitive impairment, or need for specified durable medical equipment).

Definitions

inv-11: Intensive care coordination

DefinitionRequires coordination of care across multiple providers or services to manage a chronic condition that significantly impacts health or risk of hospitalization.

PurposeDemonstrates the condition meets CMS guideline that it 'requires intensive care coordination' for SSBCI eligibility.

Examples of coordinationCare across primary care, specialists, home health, durable medical equipment suppliers, and behavioral health as needed to prevent hospitalizations.

inv-12: Activities of daily living impairment

DefinitionDifficulty with bathing, dressing, toileting, transferring, and eating related to the chronic condition.

Role in eligibilityImpairment in activities of daily living (ADLs) related to the chronic condition can be used to demonstrate the CMS impact criteria for SSBCI.

Examples listedBathing, dressing, toileting, transferring, and eating — impairment in any of these supports need for supplemental benefits.