SSBCI eligibility criteria explained: what counts as “high risk of hospitalization”

Introduction

If you are trying to use Special Supplemental Benefits for the Chronically Ill (SSBCI), the hardest part is often the eligibility language. Plans may tell you that you do not “qualify,” without clearly explaining what they mean by “high risk of hospitalization.”

Understood Care advocates can help you identify what your plan requires, gather the right documentation, and ask for a clear, written decision you can act on. If you also want to understand how these benefits show up on cards and allowances, see:

• https://understoodcare.com/uc-articles/healthy-food-benefit-vs-otc-card-whats-the-difference
• https://understoodcare.com/uc-articles/flex-cards-and-grocery-benefits-that-can-also-pay-rent-or-utilities

What this guide covers

• What SSBCI is and what it is not
• The official “chronically ill” eligibility test (all parts must be met)
• What “high risk of hospitalization” usually looks like in real life, and what plans commonly use as evidence
• How to ask your plan the right questions and what documentation tends to help
• What to do if you are told you do not qualify

SSBCI in plain language

SSBCI are extra Medicare Advantage benefits that can be offered to certain members who meet a specific legal definition of “chronically ill.” Unlike many “primarily health related” supplemental benefits, SSBCI can include supports that address day to day barriers to health, as long as the plan has a reasonable expectation that the benefit will improve or maintain your health or overall function.

Two practical things to know up front:

• SSBCI is plan specific. Your plan decides which SSBCI benefits exist and how you qualify.
• Not every flex card, grocery allowance, or “healthy benefits” card is SSBCI. Some are standard supplemental benefits offered broadly, while SSBCI is tied to the “chronically ill” test below.

If you are comparing how food benefits vary by plan design, see: https://understoodcare.com/uc-articles/deep-plan-by-plan-comparisons-of-grocery-benefits

The official SSBCI eligibility test: who counts as “chronically ill”

CMS guidance describes a “chronically ill enrollee” using three required elements. In everyday terms, you generally must meet all of the following:

• You have one or more comorbid and medically complex chronic conditions that are life threatening or significantly limit overall health or function.
• You have a high risk of hospitalization or other adverse health outcomes.
• You require intensive care coordination.

This guide focuses on the second element, but it helps to remember that plans often evaluate the three together. For example, if your plan believes you do not need intensive care coordination, it may deny SSBCI even if your medical history suggests higher risk.

What “high risk of hospitalization” means in SSBCI decisions

CMS does not provide one universal checklist that defines “high risk of hospitalization” for every person and every plan. Instead, plans are expected to use objective, clinically grounded criteria and data sources like health risk assessments and claims history to identify who meets the definition.

In practice, “high risk” usually means your situation makes an unplanned hospital stay more likely without added support. Many validated prediction models for unplanned admissions in older adults rely on a similar core set of predictors, especially prior use of urgent care, medical complexity, and functional limitations.

What plans commonly treat as evidence of higher hospitalization risk

Every plan is different, but these are common categories that often show up in real eligibility decisions.

Recent hospital or emergency care use

A history of recent utilization is one of the clearest signals that your risk is elevated, especially when it is unplanned or repeats.

Examples include:

• A hospital admission in the last 6 to 12 months
• Repeat emergency department visits
• A recent readmission shortly after discharge
• Recent stays in skilled nursing or inpatient rehabilitation after an acute event

Prior urgent care use and prior admissions are frequently included as key predictors in models designed to identify older adults at risk for unplanned hospitalization.

Multiple chronic conditions and medical complexity

Medical complexity often means:

• Multiple chronic diagnoses that interact with each other
• Symptoms that are hard to control
• A high burden of appointments, treatments, and monitoring

When a plan evaluates SSBCI, it may look for patterns suggesting instability, such as repeated exacerbations, frequent medication changes, or multiple specialists managing overlapping problems. These factors often contribute to higher predicted admission risk in older adults.

Medication burden and polypharmacy

Taking many prescription medications can increase risk through side effects, interactions, and adherence challenges. Large cohort data show that polypharmacy in older adults is associated with a higher risk of hospitalization, and risk rises as the number of daily medications increases.

If you are on many medications, a plan may view this as a marker that closer medication management and coordination could help prevent avoidable deterioration.

Functional limitations and safety events such as falls

Functional limitations can raise hospitalization risk because small changes can trigger a cascade: reduced mobility, poor nutrition, missed medications, and delayed care.

Falls are a major driver of emergency care use in older adults. CDC reports millions of emergency department visits for older adult falls each year, and falls can threaten independence and lead to serious injury.

A recent fall, repeated falls, or a fall with injury often strengthens a “high risk” argument, especially if it led to emergency care, fracture risk, or a change in ability to complete daily activities.

Cognitive, behavioral, or communication barriers that increase clinical risk

Cognitive impairment, confusion during illness, and difficulty following complex instructions can raise risk during transitions like hospital to home.

Plans may treat issues like:

• memory problems that interfere with medication safety
• difficulty communicating symptoms early
• missed follow up visits after hospitalization

These factors often matter most when they create concrete, documentable breakdowns in care, such as missed post discharge follow up or recurring medication errors. Care coordination is specifically intended to reduce these kinds of transition risks.

Social and access barriers that directly affect health outcomes

SSBCI can involve supports related to food, transportation, or home environment, but eligibility is not supposed to be based only on income or living situation without a medical basis. The Federal Register discussion of “chronic” supplemental benefits emphasizes that eligibility is tied to chronic illness status, and not unrelated factors like income alone.

That said, social determinants of health do affect risk and outcomes, and CMS describes situations where care coordination may include coordination with social services for needs like housing, transportation, or food.

A practical way to think about this is:

• Social needs alone should not replace medical eligibility.
• Social needs can support an SSBCI request when you can clearly connect them to medical risk, such as repeated hypoglycemia due to food insecurity, missed dialysis due to transportation barriers, or asthma exacerbations due to poor housing conditions.

How Medicare Advantage plans typically make the decision

Most plans combine several inputs:

• A health risk assessment and other screening tools
• Claims and utilization history (hospitalizations, ED visits, high cost conditions)
• Clinical documentation showing instability, functional impact, and need for coordination
• A determination that the benefit has a reasonable expectation of improving or maintaining your health or overall function

Importantly, “high risk” is usually stronger when it is paired with the third element, a clear need for intensive care coordination. AHRQ describes care coordination as deliberately organizing care activities and sharing information among participants to achieve safer, more effective care, including support for transitions and follow up.

Questions you can ask your plan

When you call your plan, you can use plain, specific questions. If you are a caregiver, you can ask these on behalf of a loved one.

• “Is this benefit offered as SSBCI or as a standard supplemental benefit?”
• “What is your written definition of ‘chronically ill enrollee’ for SSBCI?”
• “What criteria do you use to determine ‘high risk of hospitalization’?”
• “What documentation do you accept: hospital discharge summaries, clinician letters, medication lists, health risk assessment results?”
• “If you deny eligibility, will you send the decision in writing and explain how to appeal?”

If you want help understanding plan documents and what your plan must put in writing, this Understood Care guide can help: https://understoodcare.com/uc-articles/helping-you-understand-your-benefits

Documentation that often strengthens a “high risk” request

You do not need perfect paperwork, but you do want a clear story that ties risk to evidence.

Helpful items can include:

• A discharge summary or after visit summary from a hospital or emergency department visit
• A medication list showing high medication burden or frequent medication changes
• Notes showing repeated symptom flare ups or difficulty controlling a chronic condition
• Documentation of falls, injuries, mobility decline, or need for assistive devices
• A short clinician letter that states:
  • the chronic conditions involved
  • why you are at higher risk for hospitalization
  • what type of coordination is needed (medication management, transition support, monitoring, link to community resources)

What to do if your plan says you do not qualify

If you are denied, ask for a written decision that explains the reason. CMS guidance notes that decisions about offering SSBCI to an individual enrollee can be subject to Medicare Advantage coverage determination and appeal rules.

Practical next steps:

• Ask the plan to state which part of the “chronically ill” definition they believe you did not meet.
• Ask what additional documentation would change the decision.
• If the denial seems incorrect, consider filing an appeal using the plan’s process, especially if you have strong evidence of recent hospital or emergency care use and a clear need for care coordination.

If you want hands on advocacy support navigating eligibility, documentation, and plan communications, see: https://understoodcare.com/uc-articles/expert-help-tailored-for-your-care-journey‍

Frequently asked questions

• What does SSBCI stand for in Medicare Advantage?
  SSBCI stands for Special Supplemental Benefits for the Chronically Ill. It refers to certain supplemental benefits Medicare Advantage plans may offer to members who meet the plan’s criteria for being “chronically ill.”
• Is “high risk of hospitalization” the only SSBCI requirement?
  No. Plans generally apply a three part “chronically ill” test, and “high risk of hospitalization or other adverse health outcomes” is only one part.
• Does one hospital stay automatically make you SSBCI eligible?
  Not always. A recent hospitalization can support a “high risk” argument, but plans may also look for medical complexity and a clear need for intensive care coordination.
• Can a plan use food insecurity or transportation problems to qualify you for SSBCI?
  Plans generally need a medical basis for SSBCI eligibility. Social needs can matter when they clearly affect health outcomes and are connected to your medical risk.
• Are grocery cards and flex cards always SSBCI benefits?
  No. Some are offered broadly as supplemental benefits, while others may be offered as SSBCI to eligible members. This is why it helps to ask your plan how the benefit is classified. For more detail, see:
  https://understoodcare.com/uc-articles/healthy-food-benefit-vs-otc-card-whats-the-difference
• What keywords should I use when searching my plan documents?
  Try “SSBCI,” “Special Supplemental Benefits for the Chronically Ill,” “chronically ill,” “care coordination,” “health risk assessment,” “food and produce,” “transportation,” and “home supports.”

References

• Centers for Medicare & Medicaid Services (CMS). Special Supplemental Benefits for the Chronically Ill (HPMS memo, 04/24/2019). https://www.cms.gov/medicare/health-plans/healthplansgeninfo/downloads/supplemental_benefits_chronically_ill_hpms_042419.pdf
• Federal Register (GovInfo). Medicare Program; Contract Year 2019 Policy and Technical Changes (Final Rule, 04/16/2018). https://www.govinfo.gov/content/pkg/FR-2018-04-16/pdf/2018-07179.pdf
• Agency for Healthcare Research and Quality (AHRQ). Care Coordination. https://www.ahrq.gov/ncepcr/care/coordination.html
• AHRQ. Care Coordination Measures Atlas, Chapter 2. https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
• CMS. Care Coordination (Innovation Center key concepts). https://www.cms.gov/priorities/innovation/key-concepts/care-coordination
• Klunder JH, et al. Prediction models for unplanned hospital admissions in community dwelling older adults: systematic review. PLOS ONE (2022). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0275116
• Chang TI, et al. Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study. Scientific Reports (2020) via PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC7609640/
• Centers for Disease Control and Prevention (CDC). About Older Adult Fall Prevention. https://www.cdc.gov/falls/about/index.html
• U.S. Office of Disease Prevention and Health Promotion. Social Determinants of Health and Older Adults (Healthy People 2030). https://odphp.health.gov/our-work/national-health-initiatives/healthy-aging/social-determinants-health-and-older-adults‍

This information is for general education and does not replace medical advice from your own clinicians or care team. If you are considering PACE or have questions about PACE program food benefits, talk directly with your local PACE organization or a trusted advocate.