New for 2020, CMS is allowing Medicare Advantage plans to offer Supplemental Benefits for Chronically Ill enrollees (SSBCI). The purpose of the benefit is to assist in improving or maintaining the overall health and functionality of the enrollee. SSBCI includes supplemental benefits that are not primarily health related and may be offered non-uniformly to eligible members. Eligibility is determined by identifying the enrollee as chronically ill, and if the item or service provided has the expectation of improving or maintaining the health or overall function of the enrollee.
CMS defines a chronically ill enrollee as an individual who:
- Has one or more comorbid and medically complex chronic conditions that is life threatening and significantly limits the overall health or function of the enrollee;
- Has a high risk of hospitalization or other adverse health outcomes; and
- Requires intensive care coordination
All three criteria must be met for an enrollee to be eligible. Medicare Advantage plans do not need to outline the process used for determining an enrollee as chronically ill, however CMS will provide supporting evidence if it is determined that a specific item or service does not have a reasonable expectation of improving or maintaining the health or overall function of a chronically ill enrollee.
Examples of Non Primarily Health Related Special Supplemental Benefits for the Chronically Ill are below:
Meals, Food and Produce – Meals provided for a limited time following surgery, hospitalization etc. Food and produce provided to assist enrollees in meeting nutritional needs.
Transportation for Non-Medical Needs – Transportation not related to medical needs, such as grocery shopping, banking etc.
Pest Control – Pest control services that are necessary to ensure health and safety of chronically ill enrollee.
Indoor Air Quality – Equipment and services to improve air quality of the chronically ill enrollee such as air purifiers, cleaning supplies etc.
Social Needs Benefits – Access to community or plan sponsored programs and events to address enrollee social needs ex: community or social clubs, park passes, counseling, etc.
Complementary Therapies – Must be provided by practitioners who are licensed or certified in the state in which they practice.
Services supporting Self Direction – Plans may provide services to assist in the establishment of decision making authority for healthcare needs, provide financial literacy classes, technology education, language classes.
Structural Home Modifications: Structural modifications that assist enrollees overall function, health or mobility such as widening of hallways, permanent mobility ramps, easy use doorknobs and faucets etc.
General Supports for Living: General supports for living include plan sponsored housing consultation, subsidies for rent or assisted living communities.