CurrentPriority Health MedicarePolicy 91652

Special Supplemental Benefits for the Chronically Ill (SSBCI) Medicare Only

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This Medicare Advantage medical policy governs eligibility for Special Supplemental Benefits for the Chronically Ill, including non-primarily-health-related supplemental benefits offered to eligible chronically ill Medicare enrollees. Eligibility requires a qualifying chronic condition, elevated risk of hospitalization or adverse outcomes, and a need for intensive care coordination.

Policy Summary

PayerPriority Health Medicare

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) Medicare Only

Policy CodePolicy 91652

Change TypeNew policy

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit a provider attestation confirming that criteria A, B, and C are satisfied before SSBCI eligibility can be determined.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A, B, CRequired eligibility criteria categories

24Qualifying chronic-condition categories

1+Acute-care utilization threshold

2+Outpatient visits threshold

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CurrentPriority Health MedicarePolicy 91652

Special Supplemental Benefits for the Chronically Ill (SSBCI) Medicare Only

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Sign up for priority_health_medicare Policy 91652 alerts

Get alerted when Policy 91652 changes without checking for updates manually.

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Policy Summary

PayerPriority Health Medicare

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) Medicare Only

Policy CodePolicy 91652

Change TypeNew policy

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit a provider attestation confirming that criteria A, B, and C are satisfied before SSBCI eligibility can be determined.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A, B, CRequired eligibility criteria categories

24Qualifying chronic-condition categories

1+Acute-care utilization threshold

2+Outpatient visits threshold

Medicare onlyApplicable product line

SSBCI Eligibility Criteria

SSBCI medical necessity eligibility

Covered for SSBCI eligibility when ALL of the following criteria categories are met.

SSBCI eligibility

A. Qualifying chronic condition: The member has one or more comorbid and medically complex chronic conditions that are life threatening or significantly limit overall health or function.One or more qualifying conditions
Qualifying examples include chronic alcohol use disorder or other substance use disorders; autoimmune disorders, including polyarteritis nodosa, polymyalgia rheumatica, polymyositis, dermatomyositis, rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, or scleroderma; cancer; cardiovascular disorders, including cardiac arrhythmias, coronary artery disease, peripheral vascular disease, or valvular heart disease; chronic heart failure; dementia; diabetes mellitus or pre-diabetes; overweight, obesity, or metabolic syndrome; chronic gastrointestinal disease; chronic kidney disease; severe hematologic disorders; HIV/AIDS; acute or chronic lung disorders; chronic and disabling mental health conditions; neurologic disorders; stroke; post-organ transplantation care; conditions that may cause cognitive impairment; conditions that may cause similar functional challenges and require similar services; chronic sensory impairment affecting vision, hearing, taste, touch, or smell; conditions requiring continued therapy to maintain or retain functioning; chronic hypertension; osteoporosis; or chronic back pain.
B. High risk of hospitalization or other adverse health outcomes
- Inpatient admission: The member had one or more inpatient admissions, including behavioral-health admissions, related to the chronic condition.1 or more in the last 12 months
- Urgent care or emergency department visit: The member had one or more urgent care or emergency department visits related to the chronic condition.1 or more in the last 12 months
C. Intensive care coordination
- Home health: The member requires home health visits related to the chronic condition.Required
- Outpatient care: The member had two or more outpatient visits related to the chronic condition, including primary care, specialty care, physical or occupational therapy, behavioral health, or home health visits.2 or more in the last 12 months

Provider Requirements and Denial Risks

Documentation Required

Provider Attestation Required

Before SSBCI eligibility may be determined, the provider must submit an attestation stipulating that the Medicare member meets all three criteria: A, B, and C.

Denial Risk

All Three Eligibility Categories Must Be Met

The member must satisfy all three eligibility categories; meeting only some categories is insufficient. Failure to satisfy any required category may result in denial of SSBCI eligibility.

A: The member has one or more medically complex chronic conditions that are life-threatening or significantly limit overall health or function.
B: The member is at high risk of hospitalization or other adverse health outcomes.
C: The member requires intensive care coordination.

SSBCI Program Background

Special Supplemental Benefits for the Chronically Ill (SSBCI) are supplemental benefits that are not primarily health related and may be offered non-uniformly to eligible chronically ill Medicare Advantage enrollees. They are intended to help plans tailor benefits, address gaps in care, and improve or maintain the member’s health, quality of life, or overall function. Examples include healthy food and produce, household supplies, meal delivery, non-emergency transportation, personal care items, pest control services, and utilities.

Key SSBCI Definitions

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Benefit categorySupplemental benefits that are not primarily health related.

Eligible populationEligible chronically ill Medicare Advantage enrollees.

AvailabilityBenefits may be offered non-uniformly by Medicare Advantage plans.

Health expectationThe benefit must have a reasonable expectation of improving or maintaining the enrollee's health or overall function.

ExamplesHealthy food and produce, household supplies, meal delivery, non-emergency transportation, personal care items, pest control services, and utilities.

Criterion A

Policy Summary

PayerPriority Health Medicare

PolicySpecial Supplemental Benefits for the Chronically Ill (SSBCI) Medicare Only

Policy CodePolicy 91652

Change TypeNew policy

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit a provider attestation confirming that criteria A, B, and C are satisfied before SSBCI eligibility can be determined.

SourceLink

On This Page

Denial Risk

High-Risk Utilization Must Be Documented

For criterion B, the member must have documented high risk of hospitalization or another adverse health outcome related to the chronic condition.

At least 1 related inpatient admission, including behavioral-health admissions, within the last 12 months; or
At least 1 related urgent care or emergency department visit within the last 12 months.

Denial Risk

Intensive Care-Coordination Need Required

For criterion C, the member must require intensive care coordination related to the chronic condition.

The member requires related home health visits; or
The member had at least 2 related outpatient visits within the last 12 months, including primary care, specialty care, physical or occupational therapy, behavioral health, or home health visits.

Denial Risk

Missing Attestation Prevents Determination

Eligibility determination may not proceed without the required provider attestation stipulating that the member meets criteria A, B, and C.

Submit the attestation before requesting or completing the SSBCI eligibility determination.
A missing attestation can prevent eligibility determination and may result in denial.

The Medicare member has one or more qualifying comorbid and medically complex chronic conditions.

Severity requirementThe condition or conditions must be life threatening or significantly limit overall health or function.

Criterion thresholdOne or more qualifying conditions are required.

Criterion B: high risk of hospitalization or other adverse health outcomes

Inpatient admission pathwayOne or more inpatient admissions, including behavioral-health admissions, related to the chronic condition during the last 12 months.

Urgent or emergency care pathwayOne or more urgent care or emergency department visits related to the chronic condition during the last 12 months.

Timing and relationshipAt least one qualifying admission or visit is required, and it must be related to the chronic condition.

Criterion C: intensive care coordination

Home health pathwayThe Medicare member requires home health visits related to the chronic condition.

Outpatient-care pathwayTwo or more outpatient visits related to the chronic condition during the last 12 months.

Qualifying visit typesOutpatient visits may include primary care, specialty care, physical or occupational therapy, behavioral health, or home health visits.