Effective Dates: 01/25/2024 - Present
Identification Number:
| EM-24004
|
| Intended Audience: | All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/OCO-CSTs/OHO/OARO |
| Originating Office: | ORDP OISP |
| Title: | Medicare Advantage Special Supplemental Benefits for the Chronically Ill - One-Time-Only Instructions |
| Type: | EM - Emergency Messages |
| Program: | Title XVI (SSI) |
| Link To Reference: | See Reference at the end of this EM. |
|
Retention Date: June 24, 2024
A. Purpose
This emergency message (EM) provides instructions for evaluating Medicare Advantage (MA) Special Supplemental Benefits for the Chronically Ill (SSBCI) when making SSI income and resource determinations. These benefits are considered social services, which are not income and may not be resources in the month following receipt.
B. Background
MA plans are health plans offered by Medicare-approved private companies. These private companies are contracted by Medicare to provide medical benefits to MA plan enrollees. The Centers for Medicare and Medicaid Services administer the Medicare program which provides traditional coverage (i.e., Part A (hospital insurance) and Part B (medical insurance)). MA plans, often referred to as Part C, provide the same coverage as traditional Medicare, but have the option to offer supplemental benefits to their enrollees. Dental, vision, hearing, and gym memberships are examples of supplemental benefits that MA plans offer that are not available with traditional Medicare.
The Bipartisan Budget Act of 2018 (Public Law No. 115-123) amended section 1852(a)(3) of the Social Security Act to expand the definition of “primarily health-related” benefits to include non-medical services. Section 1852(a)(3)(D) gave MA plans flexibility to create supplemental benefits specifically for chronically ill enrollees. The newly created supplemental benefits are called Special Supplemental Benefits for the Chronically Ill (SSBCI). The law’s intent was that an SSBCI item or service would have a reasonable expectation to improve or maintain the health or overall function of the chronically ill. A chronically ill MA enrollee is defined as one who:
· 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; and
· requires intensive care coordination.
Certain MA plans issue debit cards (or “spending allowance cards”) to their enrollees for them to obtain SSBCI items or services. Generally, the debit cards are preloaded with specific dollar amounts for enrollees to pay for items or services such as healthy groceries, non-medical transportation, and household utilities. The debit cards are restricted for specific expenses and spending allowances for cards vary by MA plans. Some MA plans fund their debit cards annually, while others may fund their cards monthly or quarterly. For example, a MA plan may issue a debit card preloaded with a $50 monthly spending allowance for eligible groceries and if the entire $50 is not spent within a month, the unused funds will not carry over into the next.
NOTE: SSBCI vary by MA plans and not all MA plans issue debit cards for SSBCI items and services.
As stated above, MA plans have the flexibility to provide non-medical services as well as health related. Examples of non-medical services are:
· Meals
· Food and produce
· Transportation for non-medical needs
· Pest control
· Indoor air quality equipment and services
· Social needs benefits
· Complementary therapies
· Services supporting self-direction
· Structural home modifications
· General supports for living
NOTE: This list is not exhaustive.
C. Policy for income and resource treatment of SSBCI
Any SSBCI item or service an SSI individual receives is considered a social service and is not income, per SI 00815.050D.1 and SI 00815.050E.1.
Any retained cash SSBCI is not a resource for one month following receipt, per SI 01120.110B. Retained amounts are countable resources beginning the second month after receipt.
Non-cash SSBCI items provided by MA plans are subject to normal resource rules. For example, SSBCI items like food scales, exercise equipment, and pedometer wristwatches may be excluded as household goods and personal effects following SI 01130.430.
D. Procedure for SSBCI
Obtain the individual’s statement, either signed on an SSA-5002 or recorded on the Report of Contact page, indicating the source and amount of the SSBCI item or service. Document that the SSBCI item or service is provided under a governmental program and is not income pursuant to this EM. Also document the individual’s allegation about how much of the cash SSBCI was retained and how it was held. For more information about developing and documenting this item, see SI 00815.050D.1.b. and SI 01120.110C.
E. References
SI 00815.050 Medical and Social Services, Related Cash, and In-Kind Items
SI 01110.100 Distinction Between Assets and Resources
SI 01110.115 Assets That Are Not Resources
SI 01120.110 Certain Cash to Purchase Medical or Social Services
SI 01130.700 Identifying Excluded Funds That Have Been Commingled With Nonexcluded
Funds
EM-24004 - Medicare Advantage Special Supplemental Benefits for the Chronically Ill - One-Time-Only Instructions - 01/25/2024