Special Supplemental Benefits for the Chronically Ill (SSBCI) Eligibility Policy

Aetna® offers targeted SSBCI benefits through select Medicare Advantage plans that are designed to help improve or maintain your health and overall well-being. These benefits may be available to eligible members in plans that offer SSBCI benefits and are not limited to Special Needs Plans (SNPs). Benefits are only available to members who meet specific eligibility criteria established by CMS.

You may be eligible for SSBCI benefits if you meet all three of these requirements:

1. You have one or more chronic conditions that are medically complex and life-threatening, or that greatly limit your overall health or ability to function; and
2. You are at high risk for going to the hospital or having other serious health problems; and
3. You need a high level of care coordination

Additionally, each SSBCI benefit must have a reasonable expectation of improving or maintaining your health or overall function. 

Having a chronic condition by itself does not make you eligible for SSBCI benefits. You must meet all SSBCI eligibility requirements.

There is no application to fill out for SSBCI benefits. We follow CMS guidelines and use your health information to decide if you qualify.

We use your health information from trusted sources, such as:

• Health Risk Assessments (HRAs)
• Your Annual Wellness Visit
• In-home or Healthy Home Visits
• Care management check-ins
• Notes from your provider or clinical evaluations
• Claims and other health records

This helps us understand your health needs and see if you meet the three SSBCI requirements listed above.

We look at all of your information together to make a decision. Some benefits may have additional requirements. You can find more details in the SSBCI benefits section below.

• Clinical conditions and diagnoses
   You have a qualifying chronic or serious health condition, including behavioral health conditions.
• Health status and functional needs
   You have identified difficulty with daily activities (like bathing, dressing, cooking or managing medications) or overall health limitations.
• Patterns of care and service use
   You regularly use health care services or see multiple providers to manage your care.
• Medication and treatment complexity
   You take multiple medications or follow complex treatment plans.
• Changes in health or disease progression
   Your condition has been identified by your provider or care team as progressing or becoming more complex, and you may benefit from additional support.
• Care management or clinician review
   Your care team or provider has identified that you may benefit from additional services.
• Health-related social needs and access barriers
   You have identified challenges that make it harder to stay healthy or get care —such as access to food, housing or transportation.
   
  
  

Note: We use your medical records and other verified health information to decide if you qualify. You cannot qualify by asking for services or reporting information on your own. No single item decides eligibility. We look at all your information together when making a decision.

Regular visits with your primary care provider (PCP) help you stay healthy. Your PCP gets to know you, tracks changes, and helps you get the care you need.

Annual Wellness Visit
A yearly check-in with your PCP is available at no cost to you. It’s a simple way to talk about your health, ask questions and plan next steps.

Healthy Home Visit
A yearly in-home visit at no extra cost for eligible members. A licensed clinician checks your health and home environment. This visit supports your care with your PCP. 

Need help with your Health Risk Assessment?
Call a Health Survey Specialist at 1-855-463-0933 (TTY: 711) Monday through Friday, from 8 AM to 5 PM  to learn whether you're eligible and how to complete one.

Information from these visits, along with other verified health details, helps us understand your needs. We will use this information to decide if you qualify for certain benefits, like SSBCI.

The benefit(s) mentioned are part of Special Supplemental Benefits for the Chronically Ill (SSBCI). SSBCI conditions include but are not limited to: hypertension, hyperlipidemia, diabetes, cardiovascular disorders, and chronic lung disorders. Eligibility is determined by whether you have a chronic condition associated with the benefit(s) and you meet all other criteria. Even if you have a listed chronic condition, you may not necessarily receive the benefit because other eligibility and coverage criteria may apply. Standards and conditions vary for each benefit. Contact us to confirm the specific SSBCI condition requirements for the benefit(s) for this plan and determine your eligibility.