What documentation does a Medicare Advantage plan ask for to approve SSBCI benefits?

Introduction

If you are trying to get a Special Supplemental Benefit for the Chronically Ill (SSBCI) through a Medicare Advantage plan, it can feel confusing because the benefit is “real,” but the paperwork is not standardized.

The most important thing to know is that Medicare Advantage plans can offer SSBCI only to people who meet a federal definition of “chronically ill,” and plans must use written policies and objective criteria to decide who qualifies. That is why plans often ask for documentation, even when the benefit sounds simple.

This guide explains what plans commonly ask for, how to prepare it, and what to do if your request is denied.

Content

• Quick takeaways
• What SSBCI is and why documentation is required
• What “chronically ill” means for SSBCI eligibility
• Documentation Medicare Advantage plans commonly request
• Documentation that is specific to the type of SSBCI benefit
• How to submit documentation with fewer delays
• If your SSBCI request is denied: your rights and next steps
• Caregiver tips
• Related Understood Care resources
• FAQ
• References

Quick takeaways

• SSBCI benefits are supplemental benefits that must have a reasonable expectation of improving or maintaining your health or overall function, and they can include some benefits that are not primarily health related.
• To approve SSBCI, your plan has to confirm you meet the “chronically ill” definition and that you meet the plan’s own eligibility criteria for that specific benefit.
• Plans commonly request documentation that shows: your diagnosis, how the condition affects function or health risk, and why you need intensive care coordination.
• Plans may consider social factors (like food insecurity or housing instability) as part of the picture, but they cannot use social factors as the only reason you qualify.
• If you are denied, you can request a formal coverage decision and appeal. Medicare describes the Medicare Advantage appeals process and the levels of appeal.

What SSBCI is and why documentation is required

SSBCI is a category of Medicare Advantage supplemental benefits created so plans can better tailor support for people with complex chronic needs. Federal rules define SSBCI and set guardrails around who can receive it and what the benefit can include.

Documentation matters because your plan is not just deciding whether a benefit exists. It is also documenting that:

• You meet the federal “chronically ill” definition for SSBCI.
• You meet the plan’s written eligibility criteria for that specific SSBCI benefit.
• The benefit is expected to help maintain or improve your health or overall function based on your circumstances.

Even when you are clearly dealing with a serious condition, plans still rely on records to show how you meet each part of the eligibility standard.

What “chronically ill” means for SSBCI eligibility

Federal rules describe a “chronically ill enrollee” for SSBCI as someone enrolled in the plan who has one or more comorbid and medically complex chronic conditions that meet all of these criteria:

• The condition is life threatening or significantly limits overall health or function.
• There is a high risk of hospitalization or other adverse health outcomes.
• Intensive care coordination is required.

Your plan may use its own written processes to determine whether you meet this definition, but it still has to make and document that determination. CMS has also stated that it expects plans to document eligibility determinations based on the statutory definition.

Documentation Medicare Advantage plans commonly request

Plans differ, but the same core categories show up again and again. If you gather these upfront, you can often reduce delays.

Proof you are requesting a specific SSBCI benefit

Plans usually need clarity on what you want and how it fits the plan’s SSBCI offerings.

Common items include:

• The name of the benefit (as listed in your plan materials).
• What you are asking for (for example, “healthy food benefit,” “pest control,” “transportation,” “in home support,” or another SSBCI item or service offered by your plan).
• Dates or time period requested (one time, monthly, short term).
• Any plan forms your plan requires for a request.

Proof you meet the plan’s SSBCI eligibility criteria

Even though SSBCI is federally defined, each plan can set additional, objective eligibility criteria for its SSBCI benefits as long as they follow CMS rules. That is why plans may ask for documentation beyond a diagnosis code.

Documentation often includes a mix of medical and functional information.

Medical documentation that confirms your chronic condition and complexity

Plans may request records that show you have a chronic condition and that it is medically complex or has comorbidities.

Common examples:

• A problem list or diagnosis list from your clinician.
• Recent clinic notes that document your condition and current symptoms.
• Discharge summaries or hospital records (if recent hospitalization is relevant).
• Medication lists that reflect complex treatment needs.
• Relevant test results or imaging summaries (when they show severity or complications).

Documentation that shows risk and impact on health or function

Because SSBCI eligibility includes high risk of hospitalization or adverse outcomes and significant limits on health or function, plans may look for documentation that highlights risk and day to day impact.

Examples include:

• Notes describing falls, frailty, mobility limits, or difficulty with activities of daily living.
• Records of frequent urgent care or emergency department visits.
• Clinician documentation of exacerbations, flare ups, or unstable disease.
• Physical therapy or occupational therapy evaluations (when relevant to function).

Documentation that you need intensive care coordination

SSBCI eligibility includes the need for intensive care coordination. Plans may use evidence such as:

• A care plan or case management notes (if you have them).
• Notes showing multiple specialists involved, frequent transitions of care, or complex follow up needs.
• Evidence you are enrolled in or referred to care management, disease management, or similar programs (if your plan uses program participation as part of how it delivers SSBCI).

Documentation of social needs when it relates to health impact

Some SSBCI benefits are designed to address social factors that affect health, like food access or a safe home environment. CMS allows plans to consider social determinants of health as a factor for SSBCI, but not as the only basis for eligibility.

Depending on the benefit, plans may ask for documentation such as:

• Results of a health risk assessment or social needs screening your plan completed.
• Clinician notes linking the social need to health risk or functional decline.
• Supporting documents (for example, a utility shutoff notice if the plan benefit relates to maintaining safe home temperature for a respiratory condition).

Documentation that is specific to the type of SSBCI benefit

After your plan confirms you are eligible as “chronically ill,” it still needs documentation that supports the specific benefit you are requesting.

Below are common patterns plans use. Your plan may combine these or ask for additional items.

Food and produce benefits

Plans may request:

• Documentation of the qualifying chronic condition and related health risk.
• Documentation that the benefit is expected to maintain or improve health or function for you.
• Any plan required screening or assessment results tied to nutrition support.

Important note: federal rules list certain non-allowable categories for SSBCI, and CMS guidance discusses limits for some food related benefits. Your plan’s approved food list and rules matter for day to day use.

Home environment supports (examples: pest control, air filters, minor safety supports)

Plans may request:

• Clinician documentation of the health condition the home support is meant to help (for example, asthma, COPD, immune compromise, fall risk).
• A note connecting the home issue to symptoms or risk (for example, pests worsening respiratory symptoms).
• A brief statement of what service is requested and why it is expected to help maintain function or health.

Transportation and non-emergency logistics support

Plans may request:

• Appointment documentation or proof of medical need for the trip.
• Network or provider details (where you are going and why).
• If the benefit is non-standard, documentation of functional limitation that makes transportation a barrier.

Short term in home supports (examples vary by plan)

Plans may request:

• Documentation of functional limitations and safety risks at home.
• Clinician notes recommending short term assistance.
• A discharge plan or transition of care plan if the support is tied to recent hospitalization.

How to submit documentation with fewer delays

If you are managing this for yourself or for someone you care for, organization is your friend.

A simple way to build a “ready to send” packet

Put these items together as a single set:

• Cover page: the exact SSBCI benefit name and what you are requesting.
• Your plan member ID and contact information.
• One page summary from your clinician (or you) describing:
  • Your main chronic conditions.
  • How they limit function or increase health risk.
  • Why the requested SSBCI benefit helps maintain or improve health or function.
• Supporting records (only what is relevant).

Tips that often prevent back and forth

• Ask your plan to tell you, in writing, what documentation is missing if they say the request is incomplete.
• Keep copies of everything you submit, including dates and who you spoke with.
• If the plan allows oral requests, still follow up with a written summary so there is a clear record.

If your SSBCI request is denied: your rights and next steps

A denial does not always mean you are not eligible. Sometimes it means the plan believes documentation is missing or the request does not match the plan’s written criteria.

Ask for a formal coverage decision

In Medicare Advantage, coverage decisions are called “organization determinations.” Medicare explains that you have a right to request one, and that appeals follow if you disagree with the decision.

Strengthen the record for an appeal

If you appeal, the most helpful additions are usually:

• A short clinician letter that directly addresses:
  • The chronic condition and complexity.
  • Functional impact or health risk.
  • Why the requested benefit is expected to maintain or improve health or function.
• Any missing records the plan requested.
• A clear explanation of how you meet the plan’s stated eligibility criteria (use the plan’s own wording when possible).

Know what timelines may apply

Medicare Advantage plans must follow rules for standard and expedited decisions and notices for organization determinations. If you are worried that waiting could seriously jeopardize health or function, ask the plan about expedited handling.

Caregiver tips

• Bring the conversation back to the eligibility definition. If a plan is vague, ask which part of the “chronically ill” definition or which plan criterion they believe is not met.
• Use a one page summary. Busy offices and plans respond better when the “why” is easy to see.
• Do not assume the plan already has your records. Plans may have claims data, but they may still need clinical notes or a clear statement connecting the SSBCI benefit to health or function.
• Ask your clinician’s office for the exact documents requested. A problem list, recent note, and medication list are often faster to obtain than a full chart export.

Related Understood Care resources

• 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
• https://understoodcare.com/uc-articles/how-to-use-a-medicare-flex-card-for-groceries-approved-stores-items-declines
• https://understoodcare.com/uc-articles/dme-access
• https://understoodcare.com/uc-articles/helping-you-understand-your-benefits‍

FAQ

• What documents do Medicare Advantage plans need to approve SSBCI benefits?
  Often a diagnosis record, evidence of health or functional impact, and documentation showing you need intensive care coordination, plus any plan specific form.
• What is SSBCI in Medicare Advantage?
  SSBCI stands for Special Supplemental Benefits for the Chronically Ill. These are extra benefits for eligible chronically ill members that are expected to maintain or improve health or function.
• How do I prove I am “chronically ill” for SSBCI eligibility?
  Plans commonly use clinician documentation, diagnosis lists, and notes showing functional limitations, risk of hospitalization, and care coordination needs.
• Can a plan approve SSBCI based only on food insecurity or housing instability?
  Social needs may be considered, but they cannot be the only basis for SSBCI eligibility.
• Do I need my doctor to fill out an SSBCI form?
  Some plans request a clinician statement or attestation, especially if they need documentation tying the benefit to improved or maintained function.
• What should I include in an SSBCI request letter?
  The exact benefit name, your plan ID, your diagnoses, how the condition affects your function or risk, and a short explanation of how the benefit helps maintain or improve health.
• What if my Medicare Advantage plan denies my SSBCI benefit?
  Ask for a formal coverage decision (organization determination) and follow the plan’s appeal instructions. Add any missing documentation and a clinician summary that addresses the plan’s criteria.
• How long does SSBCI approval take in Medicare Advantage?
  Timelines vary, but Medicare Advantage plans must follow rules for standard and expedited decisions for coverage determinations.
• Are SSBCI benefits the same as an OTC card or flex card?
  Not always. Some SSBCI benefits are delivered through cards, but OTC and flex card programs can also include non-SSBCI supplemental benefits depending on the plan.

References

• https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.102
• https://www.cms.gov/medicare/health-plans/healthplansgeninfo/downloads/supplemental_benefits_chronically_ill_hpms_042419.pdf
• https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f
• https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c04.pdf
• https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M/section-422.566
• https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M/section-422.568
• https://www.medicare.gov/health-drug-plans/health-plans
• https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf
• https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans
• https://www.cms.gov/medicare/appeals-grievances/managed-care
• https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html
• https://www.cms.gov/medicare/regulations-guidance/legislation/paperwork-reduction-act-1995/pra-listing/cms-10915

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.