SSBCI qualifying chronic conditions
As the Value-Based Insurance Design (VBID) model ends Dec. 31, 2025, Medicare Advantage plans, including Dual Special Needs Plans (D-SNP), will experience changes. However, the Special Supplemental Benefits for the Chronically Ill (SSBCI) will remain a key program, continuing to support individuals with specific chronic health needs.
SSBCI allows Medicare Advantage plans to offer non-medical, health-related benefits like healthy foods and utility assistance, tailored to individuals with serious chronic illnesses. Note that unlike VBID, SSBCI does not include benefits related to prescription drugs or Part D.
To qualify, members must meet all three of the following criteria:
1. Have a qualifying condition. These include but are not limited to:
- Diabetes mellitus (type 1 or type 2)
- Cardiovascular disorders
- Chronic heart failure
- Chronic hypertension (chronic high blood pressure)
- Chronic hyperlipidemia (chronic high cholesterol)
- Autoimmune disorders
- Cancer
- Chronic alcohol use disorder and other substance use disorders (SUDs)
- Chronic gastrointestinal disease
- Chronic kidney disease (CKD)
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Dementia
- HIV/AIDS
- Immunodeficiency and immunosuppressive disorders
- Myasthenia Gravis/Myoneural Disorders and
Guillain-Barre Syndrome/Inflammatory and
Toxic Neuropathy - Neurologic disorders
- Overweight, obesity and metabolic syndrome
- Post-organ transplantation care
- Severe hematologic disorders
- Stroke
- Conditions associated with cognitive impairment
- Conditions with functional challenges and require similar services including spinal cord injuries, paralysis, limb loss, stroke and arthritis
2. Be at high risk for hospitalization or adverse health outcomes
3. Require intensive care coordination
- This includes individuals who need help managing multiple providers, medications or other complex care needs
