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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that a Medicare Advantage (MA) plan may offer special supplemental benefits for the chronically ill (SSBCI) to a chronically ill enrollee as a mandatory supplemental benefit. A special supplemental benefit for the chronically ill is a supplemental benefit that has, with respect to a chronically ill enrollee, a reasonable expectation of improving or maintaining the health or overall function of the enrollee. If approved by Medicare, a plan may offer SSBCI that are not uniform for all chronically ill enrollees in the plan. A plan may consider social determinants of health as a factor to help identify chronically ill enrollees whose health or overall function could be improved or maintained with SSBCI. You can find these rules in 42 Code of Federal Regulations (CFR), Section 422.102(f).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and you meet certain criteria, you may be eligible for additional benefits. These are called special supplemental benefits for the chronically ill. To be eligible for these additional benefits, you must have one or more of the specific eligible chronic conditions, must have a high risk of hospitalization or other adverse health outcomes, and must require intensive care coordination. The eligible chronic conditions are:
1. Chronic alcohol and other drug dependence
2. Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis, Rheumatoid arthritis, and Systemic lupus erythematosus;
3. Cancer, excluding pre-cancer conditions or in-situ status;
4. Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular disease, and Chronic venous thromboembolic disorder;
5. Chronic heart failure;
6. Dementia;
7. Diabetes mellitus;
8. End-stage liver disease;
9. End-stage renal disease (ESRD) requiring dialysis;
10. Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic purpura, Myelodysplastic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic venous thromboembolic disorder;
11. HIV/AIDS;
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and Pulmonary hypertension;
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive disorders, Paranoid disorder, Schizophrenia, and Schizoaffective disorder;
14. Neurologic disorders limited to: Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis, Huntington's disease, Multiple sclerosis, Parkinson's disease, Polyneuropathy, Spinal stenosis, and Stroke-related neurologic deficit;
15. Stroke
16. Crohn's disease
17. Ulcerative colitis
18. Anemia
19. Chronic obstructive pulmonary disease (COPD)
20. Severe mental retardation
21. Moderate to severe autism
You can find this information in Chapter 4 on pages 118 to 119 of the Plan's 2021 Evidence of Coverage.