Medicare & Long-Term Care Special Supplemental Benefits for the Chronically Ill (SSBCI)

To qualify for SSBCI, a plan member’s qualifying condition(s) must be confirmed through medical claims or a physician’s order and must meet all three of the following additional criteria:

1. Require intensive care coordination;
2. Be at high risk for hospitalization or other negative health outcomes; and
3. Have one or more of the chronic conditions listed below.

• To assess a member's risk of hospitalization or other adverse health outcomes, we look at history of hospitalization, Emergency Department visits, history of primary care provider (PCP) and specialist visits, and other healthcare usage

• To assess a member's requirement for intensive care coordination, we look at factors such as:

  1. whether they see their doctors often
  2. if they have trouble keeping their health conditions under control, or trouble taking their medications as prescribed
  3. whether they face other challenges—such as a need for housing or healthy foods—that make it harder to stay healthy

CompleteCare members need further qualifications to get SSBCI—they must have a Practitioner's Order and a Uniform Assessment System for NY (UAS-NY) completed by a registered nurse. These documents help us confirm their chronic conditions and the assistance they need with activities of daily living. Their care team reviews this information each year.

CompleteCare members must also meet the minimum requirements for a Medicaid Advantage Plus (MAP) plan. This means they must:

• Need more than 120 days of Community-Based Long-Term Services and Supports (CBLTSS); and
• Meet the minimum needs requirement
  • at least limited assistance with physical maneuvering with more than two Activities of Daily Living (ADLs); or
  • individuals with a dementia or Alzheimer’s diagnosis, assessed as needing at least supervision with more than one ADL