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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 special supplemental benefit for the chronically ill (SSBCI) 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. The Plan must have written policies for determining enrollee eligibility and 
must document its determination that an enrollee is a chronically ill enrollee. You can find this information in 
42 CFR 422.102. 
 
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 the enrollee is diagnosed with the following chronic condition(s) identified below and meet 
certain criteria, the enrollee may be eligible for special supplemental benefits for the chronically ill. 
- Autoimmune disorders, limited to: 
~ Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis, Rheumatoid arthritis, Systemic 
lupus erythematosus 
- Cancer (excluding pre-cancer condition or in-situ status) 
- Cardiovascular disorders, limited to: 
~ Cardiac arrhythmias, Chronic venous thromboembolic disorder, Coronary artery disease, 
Peripheral vascular disease 
- Chronic alcohol or other substance use disorder 
- Chronic heart failure 
- Chronic lung disorders, limited to: 
~ Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, Pulmonary hypertension 
- Chronic and disabling mental health conditions, limited to: 
~ Bipolar disorders, Major depressive disorders, Paranoid disorder, Schizophrenia, 
Schizoaffective disorder 
- Dementia 
- Diabetes mellitus 
- HIV/AIDS 
- End-stage liver disease 
- End-stage renal disease (ESRD) requiring dialysis 
- Neurologic disorders, limited to: ~ Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis, Huntingtons disease, 
Multiple sclerosis (MS), Parkinsons disease, Polyneuropathy, Spinal stenosis, Stroke-related 
neurologic deficit 
- Severe hematologic disorders limited to: 
~ Aplastic anemia, Chronic venous thromboembolic disorder, Hemophilia, Immune 
thrombocytopenic purpura, Myelodysplatic syndrome, Sickle-cell disease (excluding sickle-cell 
trait) 
- Stroke 
 
Members must also 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 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). 
 
You can find this information in Chapter 4 on pages 54 to 56 of the Plans 2023 Evidence of Coverage.