Provider Quality

Special Supplemental Benefits for the Chronically Ill (SSBCI) can be offered to Medicare Advantage (MA) members who have one or more complex chronic conditions, are at high risk for hospitalization or adverse health outcomes and require intensive care coordination. SSBCI aims to improve overall health outcomes for the chronically ill population by addressing social needs beyond traditional medical care such as food, housing, transportation, and gaps in care. The program is designed to support individuals by offering additional services beyond standard Medicare coverage.

Members must qualify for SSBCI benefits

Members must meet all three criteria to qualify:

• The member must require intensive care management.
  • The member must have a history of frequent outpatient services or specialty care and/or, evidence of poor disease control or medication adherence and/or, social or behavioral factors impacting health outcomes.

• The member must be at high risk for unplanned hospitalization.
  • The member must have a history of frequent hospitalizations or ED visits related to the chronic condition.
• The member must have a documented and active diagnosis for a qualifying chronic condition.
  • The chronic condition must be life threatening or significantly limit the overall health or function of the member.

How to Determine Eligibility

Auto Eligibility Process: We utilize internal and claims data in our internal algorithm to identify members that meet the three criteria. This automatic process refreshes weekly, and links member data across time and health plans, enabling a comprehensive view of historical claims. This process includes all members enrolled in an SSBCI-eligible plan.

Manual Eligibility Process: We may not have claims data or medical records for new members early in the year. These members can go through the manual process to have a provider attest to their eligibility.

To begin the SSBCI manual eligibility process, members must schedule an in-person office visit or contact their healthcare provider to request the attestation be completed. If an office visit is required to complete the attestation, the provider will evaluate the member’s health status during the visit and determine if they meet SSBCI criteria.

Provider Instructions for SSBCI Attestation

Providers should follow these steps to complete the attestation:

1. Visit ssbci.rrd.com.
2. Review the eligibility criteria outlined on the site (see criteria above) and evaluate the member accordingly.
3. Submit an attestation through the website confirming the member meets SSBCI eligibility requirements.
4. Submit a claim from the office visit that includes the appropriate diagnosis codes indicating the member has one or more qualifying chronic conditions listed on ssbci.rrd.com.

What Happens Next?

Once the attestation is received:

• The member will receive an approval or denial letter within 10 business days.
• If approved, the letter will include details about the specific SSBCI benefits available and instructions on how to access them.