Triple-S Advantage recognizes the unique healthcare and social needs of members living with chronic and complex health conditions. Special Supplemental Benefits for the Chronically Ill (SSBCI) are designed to support eligible members whose health conditions and individual circumstances may place them at increased risk for hospitalization, adverse health outcomes, or significant limitations in their overall health or functional status. In accordance with Section 1852(a)(3)(D) of the Social Security Act and applicable Centers for Medicare & Medicaid Services (CMS) requirements, the Triple-S Advantage has established criteria to identify members who may qualify for SSBCI. The eligibility is determined based on applicable clinical and other qualifying criteria established by the Triple-S Advantage and consistent with CMS requirements. SSBCI Eligibility Criteria To qualify for SSBCI, an enrollee must meet all applicable eligibility requirements established by the Triple-S Advantage, including the following: 1. Qualifying Chronic Condition The member must have the qualifying chronic condition(s) established by Triple-S Advantage for the applicable SSBCI benefit. Qualifying conditions may include conditions identified by CMS in the Medicare Managed Care Manual, Chapter 16-B, Section 20.1.2, as well as other chronic conditions that meet applicable CMS requirements. A member is eligible for SSBCI if he or she has at least two (2) chronic conditions from the following list where the claim was received by physician: Chronic alcohol and other drugs dependence Autoimmune disorders (RA, SLE, Polyarthritis) Cancer, excluding pre-cancer conditions or in-situ status Cardiovascular disorders are limited to cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous Thromboembolic disorder Chronic Heart Failure Dementia Diabetes Mellitus End Stage Liver disease End Stage Renal disease (ESRD) requiring dialysis Severe hematologic disorders are limited to aplastic anemia, hemophilia, immune thrombocytopenic purpura, myelodysplastic syndrome, and sickle cell disease (excluding sickle trait) HIV/AIDS Chronic lung disorders are limited to asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension Chronic and disabling mental health conditions limited to bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder Neurologic disorders limited to ALS, epilepsy, extensive paralysis, Huntington’s disease, Multiple Sclerosis, Parkinson’s disease, Polyneuropathy, Spinal Stenosis, and neurodegenerative disease Stroke (including stroke related to neurologic deficit) Crohn’s disease Ulcerative Colitis Chronic Obstructive Pulmonary Disease (COPD) Chronic Kidney Disease 2. Clinical Eligibility The member’s qualifying chronic condition must meet the applicable clinical criteria established for the SSBCI benefit, including consideration of whether the condition is life-threatening, significantly limiting the member’s overall health or functional status, or places the member at increased risk for hospitalization or other adverse health outcomes. Eligibility may be supported through available clinical information, including claims data, medical records, provider documentation, assessments, or other information available in Triple-S. TSA considers as eligible for SSBCI any member with one (1) diagnosis included in the above list and that meets one of the following criteria in the past twelve (12) months: Use of specialty or high-cost medication Has required durable medical equipment, home health services, or a Skilled Nursing Facility for at least one of the following chronic conditions: Cancer Cardiovascular disorders are limited to cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder Chronic Heart Failure Chronic lung disorders are limited to asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension End Stage Liver disease End Stage Renal disease (ESRD) requiring dialysis Neurologic disorders limited to ALS, epilepsy, extensive paralysis, Huntington’s disease, Multiple Sclerosis, Parkinson’s disease, Polyneuropathy, Spinal Stenosis, and neurodegenerative disease Stroke (including stroke related to neurologic deficit) Chronic Obstructive Pulmonary Disease (COPD) Has been hospitalized with a diagnosis from a chronic condition eligible for SSBCI Has visited the emergency room two (2) times or more with a diagnosis from a chronic condition eligible for SSBCI Physician certifies that the member has a high risk of adverse health outcomes and requires intensive care coordination 3. Additional Benefit-Specific Eligibility Criteria When applicable to the specific SSBCI benefit, the enrollee must also meet any additional eligibility criteria established by the Triple-S Advantage. Such criteria may include qualifying social or geographic factors, such as residence in a medically underserved area, as identified by the Health Resources and Services Administration (HRSA), where such criteria are applicable to the benefit. 4. Eligibility Determination Meeting a qualifying chronic condition alone does not automatically guarantee eligibility for an SSBCI benefit. Triple-S Advantage evaluates the applicable eligibility criteria and available information to determine whether the member qualifies the specific benefit. Eligibility determinations are made consistently with applicable CMS requirements and the criteria established for the benefit.
