CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Special Supplemental Benefits for the Chronically Ill (SSBCI) and Member Rewards

Defines SSBCI eligibility, specific supplemental benefits offered to qualifying Neighborhood Health Plan of Rhode Island INTEGRITY (FIDE) and Duals CONNECT (CO-DSNP) members, and annual Member Rewards and limitations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) and Member Rewards

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionUse Neighborhood's prior authorization request forms on the provider website and reference the Authorization Quick Reference Guide for covered codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$125/moadditional non-rolling healthy food allowance for INTEGRITY & CONNECT members

120 hrs/yrcompanion services (Papa Pals) for INTEGRITY members

$25Annual Well Visit reward

4 x $10diabetes-related annual rewards

Once/yr

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Coverage Criteria

inv-01: SSBCI Eligibility

Covered when ALL of the following are met

SSBCI eligibility: Member must (1) be chronically ill with one or more comorbid and medically complex chronic conditions; (2) have high risk for hospitalization or other adverse health outcomes; and (3) require intensive care coordination; AND have one or more listed life‑threatening or significantly function‑limiting conditions.

Conditions listed include autoimmune disorders; cancer; cardiovascular disorders; dementia; chronic & disabling mental health conditions; diabetes mellitus; chronic alcohol or substance use disorders; HIV/AIDS; sensory impairments (vision, hearing); immunodeficiency; chronic gastrointestinal disease; neurologic disorders; chronic heart failure; overweight/obesity/metabolic syndrome; chronic kidney disease; post-organ transplantation; chronic lung disorders; severe hematologic disorders; conditions associated with cognitive impairment; stroke.

inv-02: Covered SSBCI Benefits and Member Rewards — Neighborhood offers the following to qualifying members

Neighborhood offers the following to qualifying members:

INTEGRITY & CONNECT benefit: An additional $125 per month non‑rolling allowance for healthy food is provided to INTEGRITY (FIDE) and CONNECT (CO‑DSNP) members.$125/month

See member eligibility rules for SSBCI.

INTEGRITY-only benefit: INTEGRITY members receive up to 120 hours per year of companionship services through Papa Pals.120 hours/year

Papa Pals is not a benefit for Duals CONNECT members.

Member Rewards: Eligible members can receive annual rewards for completing specified health activities: Annual Well Visit (Reward = $25); Diabetes Eye Exam (Reward = $10); Diabetes Blood Sugar Controlled (Reward = $10); Diabetes Kidney Health Evaluation (Reward = $10); Diabetes Blood Pressure Control (Reward = $10).Once per calendar year per reward

Diabetes‑related rewards are available to members with a diabetes diagnosis who complete the specified screenings; Annual Wellness Visit reward available to all members who complete AWV.

SSBCI applicability is excluded for the following product lines: RItecare (MED), Substitute Care (SUB), Children with Special Needs (CSN), Rhody Health Partners (RHP), Extended Family Planning (EFP), Rhody Health Expansion (RHE), and Commercial (HBE).

Papa Pals companionship services are not a benefit for Duals CONNECT members. In addition, each Member Reward & Incentive may be collected once per calendar year.

Coding and Billing References

Covered Codes (reference)mixed

Covered Codes

For information on coding, reference the Authorization Quick Reference Guide.

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required when indicated by Neighborhood's coverage and medical policy criteria. Providers must submit prior authorization requests using Neighborhood's prior authorization request forms and follow the instructions in the Authorization Quick Reference Guide.

Use Neighborhood prior authorization request forms available on the Provider Forms page at www.nhpri.org
For assistance or to submit inquiries by phone, call 1-800-963-1001 (voice messaging available during and after business hours)

Note

Medicare-Guided Coverage Determinations

Neighborhood follows Centers for Medicare & Medicaid Services (CMS) guidance for Medicare-aligned members (including INTEGRITY for Duals FIDE and Duals CONNECT CO‑DSNP). Coverage determinations and medical necessity decisions rely on applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other Medicare guidelines. If Medicare guidance is absent or incomplete, Neighborhood will apply state Medicaid guidance (for FIDE members) or other widely used, peer-reviewed guidelines such as InterQual® and internal Clinical Medical Policies.

Definitions

Chronically ill — definition and qualifying attributes

DefinitionMember with one or more comorbid and medically complex chronic conditions who: (1) has high risk for hospitalization or other adverse health outcomes; (2) requires intensive care coordination; and (3) has one or more life‑threatening or significantly function‑limiting conditions.

Qualifying condition examplesAutoimmune disorders; cancer; cardiovascular disorders; dementia; chronic & disabling mental health conditions; diabetes mellitus; chronic alcohol or substance use disorders; HIV/AIDS; sensory impairments (vision, hearing); immunodeficiency; chronic gastrointestinal disease; neurologic disorders; chronic heart failure; overweight/obesity/metabolic syndrome; chronic kidney disease; post‑organ transplantation; chronic lung disorders; severe hematologic disorders; conditions associated with cognitive impairment; stroke.

Key clinical requirementsMember must both (a) be at high risk for hospitalization or other adverse outcomes and (b) require intensive care coordination in addition to having qualifying conditions.

Relation to Medicare benefitsSSBCI are supplemental to traditional Medicare and may include non‑primarily health related benefits when reasonably expected to improve or maintain health or function.

Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) are supplemental to the benefits covered by traditional Medicare and may include non-primarily health related benefits when there is a reasonable expectation of improving or maintaining health or overall function. SSBCI is offered to Medicare members who meet established chronic illness criteria and high-risk/intensive care coordination requirements.