SSBCI: Before You Promise the Grocery Benefit
Some of the most sought-after benefits in Medicare Advantage are the supplemental ones for chronically ill members: the food card, the over-the-counter allowance, the grocery benefit. For many members, especially on special needs plans, these are the benefits they care about most.. As plans transition away from VBID offerings and SSBCI becomes more prominent, agents need to understand an important distinction: SSBCI eligibility is not established simply because a member has a chronic condition. CMS has clarified and reinforced the existing requirement that plans apply objective criteria to determine whether the member meets the full SSBCI eligibility standard. Here is what The Brokerage Inc.'s compliance officer, Diana McElroy, wants agents to understand heading into AEP.
From VBID to SSBCI: what actually changed
Under the former VBID model, Medicare Advantage plans had flexibility to offer certain benefits based solely on Extra Help or LIS eligibility. With the end of VBID, some plans are offering certain supplemental benefits through SSBCI instead.
SSBCI stands for Special Supplemental Benefits for the Chronically Ill. To qualify for an SSBCI benefit, a member must meet the eligibility requirements established for that plan and benefit. Those requirements include having an eligible chronic condition, being at high risk for hospitalization or other adverse health outcomes, and requiring intensive care coordination. Having a chronic condition alone does not guarantee eligibility, and the plan is responsible for making the eligibility determination.
Verification comes first, benefits come second
This is the part agents most need to internalize. Under the old model, once a member qualified for the plan, the extra benefits were available immediately. Under SSBCI, they are not. The benefits do not turn on until the qualification has been verified.
Three requirements have to be met. The member must have one or more qualifying chronic conditions that are life-threatening or significantly limit overall health or function, be at high risk of hospitalization or other adverse health outcomes, and require intensive care coordination. Having a chronic condition by itself does not automatically qualify someone for the benefit.
The plan must determine that the member meets the SSBCI eligibility requirements before the benefit is provided. That determination is based on the plan's objective eligibility criteria and may involve claims, medical or pharmacy information, clinical assessments, care-management data, or provider attestation, depending on the carrier and plan. Agents should not tell a member that having a particular condition automatically qualifies them for a food, grocery, utility, or other SSBCI benefit.
Why this changes the agent's conversation
For agents, the practical impact lands in the expectations you set at the point of sale. If you enroll a member on the promise of a food card that they picture using next week, and that card does not activate until a provider completes verification weeks later, you have created a frustrated client and a likely complaint. The benefit was real, but the timeline you implied was wrong.
The fix is to walk the member through the verification process up front, so their expectations are clear. Explain the carrier's applicable eligibility and verification process, including any information or documentation the plan may require, and do not promise access before the plan has made its determination. A member who understands the process is far less likely to complain than one who expected instant access.
Verification processes vary by carrier, and The Brokerage Inc. is compiling each carrier's specific process and recommendations. That guidance is being published in BrokerLink by carrier as it is collected, so agents can tell consumers exactly what is needed and set accurate expectations rather than overpromising.
Right plan, not just wanted benefits
There is a deeper compliance point underneath all of this. These benefits are attractive, and sometimes the food card or grocery allowance is exactly what the consumer wants. But what a consumer wants is not always what a consumer needs. An agent's job is to run a complete needs analysis and a correct assessment, so the member ends up in the plan that genuinely fits them. Enrolling someone in a plan chiefly for a benefit they may not even qualify for is how you end up with a plan misalignment violation.
This is especially important with chronic and dual special needs plans. A dual-eligible member often pays no copays or coinsurance anyway, so the supplemental benefits become the main draw. That makes it even more important to confirm the member actually meets the chronic condition requirement and the high-risk-for-hospitalization standard, and that it gets verified, rather than assuming they qualify because they want the benefit.
One more thing before AEP: watch your SEPs
While you are tightening up your process, apply the same caution to special enrollment periods. CMS has tightened SEPs as well, and enrollment periods that agents used to place members into successfully may not be accepted anymore. Do not assume that because an SEP was approved in the past, it will be approved now. Confirm the member genuinely qualifies for the enrollment period before you enroll them or switch their plan. Once October 15 arrives, AEP becomes the default election period, but until then, the SEP you reach for needs to be one the member actually qualifies for.
Get the carrier-specific details
SSBCI is going to be a significant part of this year's conversations, and getting it right protects both your clients and your book. Watch BrokerLink for the carrier-by-carrier verification guidance as it publishes. And when you hit a situation you are not sure about, The Brokerage Inc. has compliance officers in house. Email [email protected], check the resource page in BrokerLink, or give us a call. Setting the right expectation the first time is the whole game.
This is the final installment in our three-part AEP compliance series.
Catch up on part one, Three AEP Rule Changes in Your Favor, and One That Trips Agents Up, or part two, The Complaints That Get Agents Terminated, and How to Stay Off That List
