Special Supplemental Benefits for the Chronically Ill (SSBCI)
Extra Support for Members with Certain Chronic Health Conditions
Some members may qualify for Special Supplemental Benefits for the Chronically Ill (SSBCI). These are extra benefits that go beyond standard Medicare-covered services and are designed to support the health and well-being of members with qualifying chronic conditions. These benefits are not available to every member.
SSBCI benefits may address health-related social needs and help members maintain or improve their overall health and ability to function. Depending on your plan, SSBCI benefits may include services or supports such as:
- Healthy food or meal assistance
- Utility assistance
- Non-Medical Transportation services
- Home safety modifications
- Barber/Beauty shop services
- Other benefits designed to support health and independence
Please review the Evidence of Coverage for the plan because benefits vary by plan and service area.
What Is a “Chronically Ill” Member?
Under Medicare rules, a chronically ill member generally:
- Has one or more medically complex or life-threatening chronic conditions; AND
- Is at high risk for hospitalization or other adverse health outcomes; AND
- Requires intensive care coordination.
Meeting one requirement alone does not automatically qualify persons for SSBCI benefits. You must not only have one of the following chronic conditions but also be at high risk for hospitalization or other adverse health outcomes and require a high level of care coordination.
How Eligibility Is Determined
Beginning in 2027, Medicare Advantage plans are required to publicly disclose the eligibility criteria used to determine whether a member qualifies for SSBCI benefits. CMS implemented this requirement to improve transparency and help members better understand benefit availability.
Eligibility is determined through an assessment process with your care team. Eligibility is not granted automatically at enrollment, and there is no grace period to access benefits while assessments are being processed. You may be approved before January 1 if your assessment is completed and approved in advance. If your health status changes and you no longer meet the criteria, your access to these benefits could end.
Eligibility is determined using objective plan criteria and includes:
- Diagnosis of one or more qualifying chronic conditions AND
- Assessment of risk for hospitalization or adverse health outcomes AND
- Need for intensive care coordination
Not all members with a chronic condition will qualify for SSBCI benefits. Meeting only one or two of these requirements does not qualify you. Having a specific diagnosis — such as ESRD or COPD — does not automatically make you eligible.
The plan must also determine that each individual benefit (i.e. non-medical transportation, utility assistance, barber/beauty shop, etc….) has a reasonable expectation of improving or maintaining health or function. This means eligible members may qualify for some benefits and not others.
Important Eligibility Information
Special Supplemental Benefits for the Chronically Ill are not available to all members. Eligibility is based on having one or more qualifying chronic conditions and meeting plan-defined eligibility criteria. Not all members with a chronic condition will qualify. Benefits, limitations, restrictions, and eligibility requirements vary by plan.
This language reflects CMS’s requirement that plans clearly explain that SSBCI benefits are limited to qualifying members and are not uniformly available to all enrollees.
Frequently Asked Questions
If I have a chronic condition, do I automatically qualify?
No. Having a chronic condition alone does not automatically qualify you for SSBCI benefits. You must also be at high risk for hospitalization or other adverse health outcomes and require a high level of care coordination.
Are SSBCI benefits available to every member?
No. These benefits are available only to members who meet the plan’s SSBCI eligibility criteria.
How do I find out if I qualify?
Contact your Care Management team or Member Services for information about your plan’s specific SSBCI eligibility requirements and benefit offerings.
Can eligibility change?
Yes. Your eligibility is determined based on health status and plan criteria. Eligibility may be reviewed throughout the year in accordance with plan requirements and Medicare regulations.
Need Help?
If you have questions about SSBCI benefits or would like more information about eligibility requirements, please contact Member Services at Oregon: 1-844-854-6885 (TTY 711) and Washington: 1-844-854-6885 (TTY 711) .
Our hours of operation are April 1 – September 30: 8 am – 8 pm local time, Monday – Friday and October 1 – March 31: 8 am – 8 pm local time, 7 days a week. Note: Member Services is closed on the following holidays: Memorial Day, Independence Day, Thanksgiving, and Christmas.
The benefits mentioned are part of special supplemental benefits for the chronically ill (SSBCI). Not all members qualify. To be eligible, a member must have a qualifying chronic condition, be determined by the plan and a healthcare provider to be at high risk for hospitalization or other adverse health outcomes, and require a high level of care coordination. Even if a member has a qualifying chronic condition, they may not receive these benefits. Coverage depends on the plan’s specific eligibility criteria and clinical determination. Members may be required to complete an assessment with the plan’s care team to confirm eligibility throughout the year.