Changes to special supplemental benefits for the chronically ill eligibility requirements

Effective January 1, 2025, Anthem will change its process for approving members for special supplemental benefits for the chronically ill (SSBCI), such as groceries, utilities, chronic meals (for more than 90 days), and nonemergency transportation to non-health-related destinations.

Per CMS guidelines, to be eligible for SSBCI benefits, a member must have a qualifying chronic condition and meet all the criteria below:

1. Has one or more comorbid and medically complex chronic conditions that are life threatening or significantly limit the overall health or function of the enrollee
2. Has a high risk of hospitalization or other adverse health outcomes
3. Requires intensive care coordination

To ensure that members, care providers, and other clinical teams have a clear understanding of eligibility requirements, Anthem has established a set of Clinical Guidelines that we believe equate to the above criteria. In short, a member would be deemed eligible for an SSBCI benefit if they:

• Have a valid chronic condition as listed in their Evidence of Coverage (EOC)
• And any of the following are true:
  • Had one or more inpatient admissions (inclusive of behavioral health) related to the chronic condition in the last 12 months
  • Had one or more urgent care or emergency room visits related to the chronic condition in the last 12 months
  • Had two or more outpatient visits related to the chronic condition (including primary care or specialty care visits) in the last 12 months
  • Are a patient who requires home health visits related to the chronic condition
  • Are a patient who has an impairment in daily living activities related to the chronic condition (bathing, dressing, toileting, transferring, and eating) or cognitive impairments
  • Are a patient with one or more chronic conditions and a need for one or more pieces of durable medical equipment (DME) in the outpatient setting, including but not limited to: group 3 power/manual wheelchair, noninvasive ventilation (NIV), wound vacuums, bipap machines, mechanical in-exsufflation devices, or group 2 or group 3 mattresses
  • Are successfully enrolled in a chronic special needs plan (CSNP)

In the past, Anthem and many other plans used a member’s chronic condition as the principal cause for eligibility. As a result of the revised guidance, Anthem will need to ensure that all new members as well as those previously approved meet the criteria above.

Use of care provider confirmations to support eligibility

When insufficient evidence is available for Anthem to render an organizational determination on a member’s eligibility, Anthem will request a medical review by its participating care providers that a member meets the clinical guidelines listed above.

The request will generally be faxed to care providers as an SSBCI Provider Confirmation Form, preprinted with member information and including instructions and reference materials such as a summary of eligible conditions and applicable Clinical Guidelines. Since these requests impact a member’s access to benefits, we are requesting that they be treated like any other organizational determination request, preferably returned within three to five days of receipt.

The process for both new and existing members will begin in October 2024 and will impact members’ benefits for the 2025 plan year.

Additional notes for care providers delegated for utilization management by Anthem

For care providers delegated by Anthem for utilization management, this process is being retained by Anthem as it applies to supplemental benefits, which generally are not included in such delegation. Consequently, we ask that these care providers please follow the guidance provided above and work directly with Anthem to establish member eligibility for SSBCI benefits.

For answers to other questions, contact your Provider Services representative.