SSBCI Attestation Form

 

Attestation
Special Supplemental Benefits for the Chronically Ill

Instructions:

DrMax-B (009) and DrSelect (012) offer a benefit of a Pre-Paid Grocery / OTC Card.  The benefit dollar amount is listed on the website in the Summary of Benefits and Evidence of Coverage. 

In order for a member to obtain the Pre-Paid Grocery & OTC card, the member must first meet criteria as listed below.  CMS guidance requires a physician, the member’s PCP, to attest to the 3 questions in order for the member to qualify to receive the SSBCI benefit. 

Our health plan provides Special Supplemental Benefits for Chronically Ill (SSBCI) to our highest-risk members who meet specific criteria for eligibility based on CMS guidelines.

To determine eligibility, PCP physician must complete the online form below within 15 calendar days.

After we receive and validate all criteria are met, we will send an approval or denial letter to the member to let them know if they meet the criteria and how to activate the benefits.

All three of the criteria below must be met and confirmed by the physician in order to qualify for the Special Supplemental Benefits for the Chronically Ill (SSBCI) Pre-Paid grocery and OTC card:

• The member must require intensive care coordination
  This is based on physician assessment of patient requiring intensive care coordination.
• The member must be at high risk for hospitalization or other adverse health outcomes
  This is based on physician assessment of patient being at high-risk for unplanned hospitalization or other adverse health outcomes.
• The member must have a documented and active diagnosis
  Does the member have one or more of the qualifying comorbid and medically complex chronic conditions (see Chronic Condition list below) that is life threatening or significantly limits the overall health or function of the member.

Member Diagnosis (please identify and list all applicable from Chronic Condition list below):

You may also provide the information by downloading the form from the following link. Once you have filled it out, you can either:

1. Fax the completed form to: (786) 578-0287, or
2. Email the form using the following link.  

Important Benefit Information for Enrollees with Chronic Conditions:

If the member is diagnosed with the following chronic condition(s) identified below and meets certain criteria, the member may be eligible for special supplemental benefits for the chronically ill.  Please see the list below of eligible Chronic Conditions.  The Chronic Condition(s) must be designated on the previous page in order for the member to qualify for the Special Supplemental Benefit for the Chronically Ill (SSBCI).  

Chronic Conditions are:

• Autoimmune disorders
  • Polyarteritis nodosa (also known as PAN, inflammation and weakening in arteries)
  • Polymyalgia rheumatica (also known as PMR, inflammation/pain/stiffness in shoulders and hips)
  • Polymyositis (also known as inflammatory myopathy, muscle weakness)
  • Rheumatoid arthritis (also known as RA, pain/stiffness in joints)
  • Systemic lupus erythematosus (also known as Lupus)
• Cancer
  • Cancer (excluding pre-cancer conditions or in-situ (stage 0) status)
• Cardiovascular disorders
  • Cardiac arrhythmias (also known as abnormal heart rhythm)
  • Coronary artery disease (also known as history of chest pains, heart attacks, or hardening of the arteries of the heart))
  • Peripheral vascular disease (also known as hardening of the arteries of the legs)
  • Chronic venous thromboembolic disorder (also known as blood clots in the legs)
• Chronic alcohol or other substance use disorder
• Chronic Heart Failure
  • Chronic heart failure
  • Congestive Heart Failure
• Chronic lung disorders
  • Asthma
  • Chronic bronchitis
  • Emphysema
  • Pulmonary fibrosis (also known as scarring of lung tissue)
  • Pulmonary hypertension (lungs) (also known as high blood pressure in the lungs)
• Chronic and disabling mental health conditions
  • Bipolar disorders
  • Major depressive disorders
  • Paranoid disorder
  • Schizophrenia
  • Schizoaffective disorder
• Dementia
• Diabetes mellitus
  • Diabetes mellitus (also known as Diabetes Type I or Type II)
• HIV/AIDS
• End-stage liver disease
• End-stage renal disease (ESRD) requiring dialysis
• Neurologic disorders
  • Amyotrophic lateral sclerosis (ALS)
  • Epilepsy
  • Extensive paralysis (hemiplegia, quadriplegia, paraplegia, monoplegia)
  • Huntington’s disease
  • Multiple sclerosis (MS)
  • Parkinson’s disease
  • Polyneuropathy
  • Spinal stenosis
  • Stroke-related neurologic deficit
• Severe hematologic disorders
  • Aplastic anemia
  • Hemophilia
  • Immune thrombocytopenic purpura
  • Myelodysplastic syndrome
  • Sickle-cell disease (excluding sickle-cell trait)
  • Chronic venous thrombocytopenic disorder
• Stroke