Wellcare offers Special Supplemental Benefits for the Chronically Ill (SSBCI) benefits to eligible members who are enrolled in a Wellcare plan that offers SSBCI benefits and meet specific eligibility requirements. These benefits are available to members who are diagnosed with one or more eligible chronic conditions and who meet all CMS-defined eligibility criteria requirements:
- Has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee
- Has a high risk of hospitalization or other adverse health outcomes
- Requires intensive care coordination
Qualifying chronic conditions may include, but are not limited to, the following:
- Autoimmune disorders
- Cancer
- Cardiovascular disorders
- Chronic alcohol use disorder and other substance use disorders (SUDs)
- Chronic and disabling mental health conditions
- Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell
- Chronic gastrointestinal disease
- Chronic heart failure
- Chronic kidney disease (CKD)
- Chronic lung disorders
- Conditions associated with cognitive impairment
- Conditions that require continued therapy services in order for individuals to maintain or retain functioning
- Conditions with functional challenges
- Dementia
- Diabetes mellitus
- Endometriosis
- HIV/AIDS
- Immunodeficiency and Immunosuppressive disorders
- Neurologic disorders
- Overweight, obesity, and metabolic syndrome
- Post-organ transplantation
- Severe hematologic disorders
- Stroke
How Eligibility is Determined
A diagnosis of a chronic condition alone does not guarantee eligibility. In addition to having one or more qualifying chronic conditions, eligibility for SSBCI is demonstrated by the member having one or more of the following:
- A history of hospitalization or ED visits, and/or
- Frequent use of outpatient services or specialty care, and/or
- Evidence of poor disease control or medication adherence, and/or
- Non-medical social needs that impact health outcomes
Eligibility is determined after you are enrolled in the plan using objective, documented criteria based on available information such as medical records, claims, care management assessments, provider documentation, and other supporting information.
For new members without sufficient claims history, a provider attestation may be submitted to support the eligibility review. Submission of an attestation does not guarantee approval, as eligibility is determined based on whether the member meets all required eligibility criteria.
Confirmation that all eligibility criteria are met is required before receiving access to benefits. Wellcare will notify you if eligible and provide instructions on how to access SSBCI benefits.
SSBCI eligibility applies only to the current plan year and ends on December 31st. Members must meet eligibility requirements each plan year to continue receiving these benefits.
Note: Benefits mentioned are a part of Special Supplemental Benefits for the Chronically Ill. Not all members will qualify. In addition to being high-risk, you must have one or more of the following chronic conditions: cancer, cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, diabetes. There are other eligible conditions not listed. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us or see the plan’s Evidence of Coverage.
