Qualifications for Special Supplemental Benefits for the Chronically Ill (SSBCI)
About the SSBCI program
The Special Supplemental Benefits for the Chronically Ill (SSBCI) program helps eligible UnitedHealthcare Medicare Advantage members access certain benefits, such as healthy food and utility benefits, depending on their plan.
To qualify for SSBCI benefits, Medicare requires us to verify that you:
- Have at least one qualifying chronic condition
- Are at high risk of hospitalization or adverse health outcome
- Require intensive care coordination
How we determine whether you qualify
To qualify for SSBCI benefits, you must meet the requirements in all 3 steps outlined below. We use objective criteria and review information available through our health plan records and other approved sources to determine whether you qualify.
We must confirm your qualifying condition through available health plan records or with your treating provider. A statement that you have a qualifying condition, by itself, is not sufficient.
Step 1: Verify you have a qualifying chronic condition
First, we verify that you have at least one of the following qualifying chronic conditions:
- Diabetes mellitus (type 1 or type 2)*
- Cardiovascular disorders*
- Chronic heart failure*
- Chronic hypertension (chronic high blood pressure)
- Chronic hyperlipidemia (chronic high cholesterol)
- Autoimmune disorders
- Cancer
- Chronic alcohol use disorder and other substance use disorders (SUDs)
- Chronic gastrointestinal diseases
- Chronic kidney disease (CKD)
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Dementia
- HIV/AIDS
- Immunodeficiency and immunosuppressive disorders
- Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome/Inflammatory and Toxic Neuropathy
- Neurologic disorders
- Overweight, obesity and metabolic syndrome
- Post-organ transplantation care
- Severe hematologic disorders
- Stroke
- Conditions associated with cognitive impairment
- Conditions that cause functional challenges and require similar services, including spinal cord injuries, paralysis, limb loss, stroke or arthritis
*If you are enrolled in a Chronic Condition Special Needs Plan, or C-SNP, the qualifying conditions are the same conditions used to determine your eligibility for that plan: diabetes, a cardiovascular disorder or chronic heart failure.
Step 2: Determine if you are at high risk of hospitalization or an adverse health outcome
In addition to having a qualifying chronic condition under Step 1, you must meet at least one of the following criteria:
- Receive Extra Help from Medicare
- Have had an emergency room visit, observation stay or inpatient hospital admission during the past 12 months
- Take 5 or more ongoing prescription medications, excluding short-term medications used to treat temporary illnesses or infections
- Have a combination of chronic conditions associated with a higher risk of hospitalization
- Have social or behavioral risk factors identified through a Health Risk Assessment (HRA)
Step 3: Determine if you require intensive care coordination
In addition to meeting the requirements in Steps 1 and 2, you must meet at least one of the following criteria:
- Be enrolled in a Special Needs Plan
- Have 2 or more Medicare-recognized chronic conditions
- Have more than one visit with a specialist per year
- Receive care from multiple specialists across different specialties within a year
- Live in a rural area where coordinating care may be more difficult
- Be assessed as moderate, moderate-high or high risk based on a Health Risk Assessment (HRA)
- Be eligible for Long-Term Services and Supports (LTSS)
How we verify information
We may use available health plan or third-party data to determine whether you qualify for SSBCI benefits. If we need more information, we may ask for:
- Your treating provider's contact information
- Your permission, through a HIPAA authorization, to review certain health plan information or use third-party data
- Additional information needed to confirm you qualify
- Your permission to contact a Medicare Advantage plan in which you were previously enrolled
If needed, we may also contact your treating provider to confirm your diagnosis.
Annual review
We review your information each year to confirm that you continue to qualify for SSBCI benefits. You must continue to meet the program requirements to receive these benefits.
If you do not qualify
If we cannot verify that you meet all SSBCI requirements, you will not be able to access SSBCI benefits. This will not affect your eligibility for your Medicare Advantage plan or your other plan benefits.
If your health or circumstances change
We will continue to review available information throughout the year. If we later determine that you meet the SSBCI requirements, your benefits will become available after we confirm that you qualify. We’ll send you a letter letting you know when you can start using your benefits.
If you believe you qualify
If you believe you meet the SSBCI requirements but we were unable to confirm that you qualify, call the number on your UnitedHealthcare member ID card. We can explain what additional information may be needed and how your treating provider can help us verify your eligibility.
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