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Decision: unknown

 
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 say that plans may offer a supplemental benefit to provide services for the Chronically Ill. Plans may 
offer Enhanced Disease Management (EDM) as a supplemental benefit. EDM must be targeted to groups of 
enrollees based on a diagnosis of, or risk for, a specific disease condition (e.g., diabetes, heart failure, cognitive 
impairment such as Alzheimers and related dementias). Services that CMS would expect to be included in a  
supplemental EDM benefit for coordinated care plans, and which would be expected to be approved as 
supplemental benefits, would include the following three activities:  
 
Enrollees in the target group are assigned to qualified case managers with specialized knowledge about the 
disease(s) who contact the enrollee to provide additional case management and monitoring services. 
 
Educational activities being provided by certified or licensed professionals that are focused on the specific 
disease/condition. 
 
Routine monitoring of measures, signs and symptoms, applicable to the specific disease(s)/condition(s) of the 
enrollee. You can find this rule in the Medicare Managed Care Manual, Chapter 4, Section 30.3. 
 
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 
says that our plan includes Special Supplemental Benefits for the Chronically Ill (SSBCI). These supplemental 
benefits are only offered to high-risk, chronically ill members who also meet additional criteria for eligibility. 
 Members must meet and maintain all three eligibility criteria below to qualify: 
1. The member must require intensive care management. 
 Based on physician assessment of patient having had 2 or more inpatient admissions in the last 60 days OR 
having had 3 or more emergency room visits in the last 60 days. 
2. The member must be at high risk for hospitalization. 
 Based on physician assessment of patient being at high-risk for unplanned hospitalization in the next 60 days. 
3. The member must have a documented and active diagnosis for one or more of the qualifying comorbid and 
medically complex conditions. The condition must be life threatening or significantly limit the overall health or 
function of the member. 
 After required office visit, physician to submit claim showing diagnosis code(s) for qualifying eligible 
condition(s). 
 Eligibility is determined at the discretion of your plan through processes that review claims history, risk classification, and other information. Members who cannot be automatically qualified will be required to 
schedule a visit with their physician to ensure sufficient documentation (e.g. claims, qualifying assessment) are 
available to validate eligibility. Copays or other costs not covered by your plan may apply. 
 Confirmation that all criteria has been met is required prior to receiving access to these benefits. 
 
You can find this information in Chapter 4 on pages 55-57 of the Plan's 2023 Evidence of Coverage.