For 2027, the Center for Medicare and Medicaid Services introduced new rules for the Special Supplemental Benefits for the Chronically Ill (SSBCI) program, which helps eligible Medicare Advantage members access certain benefits, such as healthy food and utility benefits, depending on their plan.
All insurance carriers must abide by and enforce these rules.
Medicare Beneficiaries cannot avoid these rules by moving to a different insurance carrier. If a health insurance agent suggests you can avoid these rules, they are seriously misinforming you. If the agent applies for you, and you don’t qualify, you won’t receive the over-the-counter allowances for food and utility expenses, and you may be responsible for unexpected costs.
To qualify for SSBCI benefits, Medicare requires us to verify that you:
- Have at least one qualifying chronic condition
- Are at high risk of hospitalization or adverse health outcome
- Require intensive care coordination
How the insurance carrier determines whether you qualify
To qualify for SSBCI benefits, you must meet the requirements in all 3 steps outlined below. The insurance carrier uses objective criteria and reviews information available through its health plan records and other approved sources to determine whether you qualify.
The insurance carrier must confirm your qualifying condition through available health plan records or with your treating provider. A statement that you have a qualifying condition, by itself, is not sufficient.
Step 1: Chronic Special Needs Plan (C-SNP)
When applying for a Chronic Special Needs Plan (C-SNP), the insurance carrier must verify you have one of these qualifying chronic conditions:
- Diabetes mellitus: Type 1 or Type 2
- Cardiovascular disorders
- Chronic heart failure
Step 1: Dual Special Needs Plan (D-SNP) and
All Medicare Advantage Plans That Offer a Food and Home Utility Allowance.
When applying for any Medicare Advantage Plan that offers a food and home utility allowance, especially a Dual Special Needs Plan (D-SNP, the insurance carrier must verify you have one of these qualifying chronic conditions:
- 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 diseases
- 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 that cause functional challenges and require similar services, including spinal cord injuries, paralysis, limb loss, stroke or arthritis
Step 2: Determine if you are at high risk of hospitalization or an adverse health outcome
In addition to having a qualifying chronic condition under Step 1, you must meet at least one of the following criteria:
- Receive Extra Help from Medicare
- Have had an emergency room visit, observation stay or inpatient hospital admission during the past 12 months
- Take 5 or more ongoing prescription medications, excluding short-term medications used to treat temporary illnesses or infections
- Have a combination of chronic conditions associated with a higher risk of hospitalization
- Have social or behavioral risk factors identified through a Health Risk Assessment (HRA)
Step 3: Determine if you require intensive care coordination
In addition to meeting the requirements in Steps 1 and 2, you must meet at least one of the following criteria:
- Be enrolled in a Special Needs Plan
- Have 2 or more Medicare-recognized chronic conditions
- Have more than one visit with a specialist per year
- Receive care from multiple specialists across different specialties within a year
- Live in a rural area where coordinating care may be more difficult
- Be assessed as moderate, moderate-high or high risk based on a Health Risk Assessment (HRA)
- Be eligible for Long-Term Services and Supports (LTSS)
See next page to learn how the insurance carrier verifies you.
How the insurance carrier verifies your information
The insurance carrier may use available health plan or third-party data to determine whether you qualify for SSBCI benefits. If the insurance carrier needs more information, it may ask for:
- Your treating provider’s contact information
- Your permission, through a HIPAA authorization, to review certain health plan information or use third-party data
- Additional information needed to confirm you qualify
- Your permission to contact a Medicare Advantage plan in which you were previously enrolled
If needed, the insurance carrier may also contact your treating provider to confirm your diagnosis.
Annual review
The insurance carrier reviews your information each year to confirm that you continue to qualify for SSBCI benefits. You must continue to meet the program requirements to receive these benefits.
If you do not qualify
If the insurance carrier cannot verify that you meet all SSBCI requirements, you will not be able to access SSBCI benefits. This will not affect your eligibility for your Medicare Advantage plan or your other plan benefits.
If your health or circumstances change
The insurance carrier will continue to review available information throughout the year. If the insurance carrier later determines that you meet the SSBCI requirements, your benefits will become available after the insurance carrier confirms that you qualify. The insurance carrier sends you a letter letting you know when you can start using your benefits.
If you believe you qualify
If you believe you meet the SSBCI requirements, but the insurance carrier is unable to confirm that you qualify, call the phone number on your insurance carrier member ID card. The insurance carrier can explain what additional information may be needed and how your treating provider can help us verify your eligibility.
New rules for coverage were implemented by the Center for Medicare and Medicaid Services in 2026 and cannot be altered, modified or ignored by any insurance carrier or a health insurance agent. This information was gathered from the Center for Medicare and Medicaid Services and the UnitedHealthcare Medicare Advantage website.
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