The Pronounced Importance of an Unpronounceable Acronym: New Guidance on SSBCI in Medicare Advantage

On April 24, Centers for Medicare and Medicaid Services (CMS) issued a memo to Medicare Advantage (MA) plan sponsors detailing the scope of Special Supplemental Benefits for the Chronically Ill (SSBCI). Established by the Bipartisan Budget Act of 2018 and further defined in the CMS’ 2020 Call Letter, SSBCI is a new category of supplemental benefit that can be offered by Medicare Advantage (MA) plans to chronically ill enrollees.

As noted by CMS in previous guidance, for 2020, there will be three different categories of supplemental benefits, including:

• Standard supplemental benefits that are uniformly offered to all enrollees
• Targeted supplemental benefits that are offered only to qualifying enrollees (determined by health status or disease state)
• SSBCI supplemental benefits that are offered to enrollees who are chronically ill (as defined by CMS in previous guidance)

Historically, CMS tightly regulated supplemental benefits; these benefits had to be primarily health related – such as dental and vision coverage – and uniformly administered (first bullet above). Over the last two years, CMS broadened the scope of allowable benefits within the “primarily health related” standard and permitted those benefits to be offered only to qualifying enrollees (second bullet above). SSBCI (third bullet above) replaces that “primarily health related” standard with a more permissive standard: “reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee” which dramatically expands the continuum of permissible benefits. The April 24 guidance defines what is permissible under this new reasonable expectation standard.

CMS notes that MA plan sponsors have “broad discretion in determining what may be considered a reasonable expectation.” CMS will let MA plan sponsors propose what meets this standard and the agency promises to “provide supporting evidence or data” to the MA plan sponsor if it rejects a proposed SSBCI benefit.

While CMS previously noted into the 2020 Call Letter that SSBCI could only be triggered by a chronic illness and not a social determinant of health (SDOH), the April 24 guidance nuances this position:

MA plans may consider social determinants of health as a factor to help identify chronically ill enrollees whose health could be improved or maintained with SSBCI and they may use social determinants to further limit SSBCI eligibility. However, they may not use social determinants of health as the sole basis for determining eligibility for SSBCI. [boldface added]

Most importantly, the April 24 guidance offer a detailed list of SSBCI permissible benefits that includes a number of services not mentioned in previous guidance including: food and produce, social needs benefits, services supporting self-direction, and general supports for living. The guidance also clarifies the full extent to which previously discussed SSBCI benefits can be offered. CMS makes several clarifications with respect to specific SSBCI benefits, including:

• Meal benefits “may be offered beyond a limited basis” (previously, meal benefits were limited to post-acute care episodes of care)
• Transportation benefits may be offered for a wide set of non-healthcare activities including grocery shopping and banking (previously, transportation benefits could only be used for medical appointments and pharmacy visits)
• Home modification benefits can include “widening of hallways or doorways, permanent mobility ramps, easy use doorknobs and faucets” (previously, CMS had warned MA plan sponsors not to make home modifications that might be considered capital improvements)

CMS further clarifies SSBCI administration by noting that:

• Retroactive member reimbursement is a permissible mechanism for offering SSBCI
• SSBCI can be (accurately) discussed in marketing materials
• SSBCI can be subject to limitations as designed by the MA plan sponsor

SSBCI are limited by the availability of rebate funds and can only be offered to MA plan enrollees with a chronic illness. However, favorable MA payment updates in the last two years suggest that MA plan sponsors, generally speaking, will have rebate funds to tap. And CMS suggests in its Call Letter that 73 percent of Medicare Advantage enrollees have a qualifying chronic illness.

With all of this in mind, it is not hyperbolic to suggest that SSBCI creates an enormous benefits gap between what is available in original Medicare vs. what will soon be available to certain beneficiaries in Medicare Advantage. This gap may take years to fully materialize as plans become more experienced with the full scope of supplemental benefits available. While SSBCI may be an unpronounceable acronym, it may ultimately create a pronounced opportunity for Medicare Advantage plans and their enrollees.