Beginning Jan. 1, 2027, Medicare members on the following plans may be eligible for Special Supplemental Benefits for the Chronically Ill (SSBCI):
- PriorityMedicare Align (HMO-POS)
- PriorityMedicare Latitude (HMO-POS)
- PriorityMedicare D-SNP (HMO)
- PriorityMedicare Dual Premier (HMO D-SNP)
Some members who already receive SSBCI will have their eligibility renewed. For others, a provider must attest on the member’s behalf that they have all of the following:
- One or more qualifying conditions (see below for the full list)
- A high risk of hospitalization or other adverse health outcomes
- A need for intensive care coordination
- Clinical rationale for receiving SSBCI
How do providers attest?
There are two options for providers to attest on a member’s behalf that they qualify for SSBCI (both upon member request):
- Fill out our online SSBCI provider attestation form on prism, using the Resources dropdown (or, after Jan. 1, on the new Provider Portal)
- Complete and submit the paper application provided by the member
As members select new plans for 2027, you may also be asked to complete these forms for plans that begin in the new year.
What are SSBCI?
SSBCI include allowances for healthy food and produce for all eligible members, as well as personal care items, household supplies, utilities, pest control and online meal delivery for dual-eligible members (those with D-SNP and Dual Premier plans). These are crucial for addressing social and environmental impacts to some members’ health, particularly those with chronic conditions.
Why is the eligibility process changing?
As CMS continues to tighten eligibility requirements for SSBCI, we’re ensuring we remain in compliance by having providers attest to members’ needs for these additional benefits. With your assistance completing these attestations, we can continue addressing many of our Medicare members’ social determinants of health in accordance with CMS regulations.
When will members begin requesting SSBCI attestation?
Requests may come in as early as Oct. 15, as members begin enrolling for 2027. Requests may come in at any point after that since members won’t be able to receive SSBCI until they have provider attestation that they qualify.
What if the member doesn’t qualify? What if I don’t have enough information?
Complete the attestation form upon member request even if the member doesn’t qualify for SSBCI. Priority Health will make the eligibility decision based on what’s indicated on the completed form.
If you need more information to complete the form, you may request a formal office visit or wellness check with the member to gather the information you need.
What are the qualifying conditions?
The following is a general list of SSBCI-qualifying conditions (see the form for more details):
- Chronic alcohol use disorder and other substance use disorders
- Autoimmune disorder
- Cancer
- Cardiovascular disorder
- Chronic heart failure
- Dementia
- Diabetic condition
- Overweight/obesity/metabolic syndrome
- Chronic gastrointestinal disease
- Chronic kidney disease (CKD)
- Severe hematologic disorder
- HIV/AIDS
- Acute/chronic lung disorder
- Severe acute respiratory failure
- Presence of a tracheostomy
- Chronic and disabling mental health condition
- Neurologic disorder
- Stroke
- Post-organ transplantation care
- Condition causing cognitive impairment
- Condition causing physical impairment
- Chronic condition that impairs vision, hearing, taste, touch or smell
- Condition requiring continued therapy services to maintain/retain functioning
- Chronic hypertension
- Osteoporosis
- Chronic back pain