Special Supplemental Benefits for the Chronically Ill: 2025 Proposed Rule Impacts to Consider

Believe it or not, it is already time to start thinking about plan benefits for contract year 2025. Plan sponsors continue to look for ways to grow membership, modify benefit offerings, and improve beneficiary health and outcomes.  One method is offering supplemental benefits to the chronically ill, which has increased in popularity with plan sponsors and beneficiaries alike since 2019.  CMS shared their intent to encourage greater utilization of benefits by imposing additional operational requirements in their proposed rule changes for 2025 (HHS_FRDOC_0001-0918).

The proposed rule shared that because of oversight and monitoring, CMS is seeing a wide range of benefits now being offered as supplemental benefits, which has also increased the amount of rebate dollars plans are receiving to offer them.  Given that, CMS is not seeing beneficiaries using the benefits at a rate to match.  This may be due to incorrect targeting of enrollee’s conditions by plan sponsors, beneficiary confusion, or another reason yet to be determined. CMS is proposing that plans offering special supplemental benefits for the chronically ill do a better job of making sure beneficiaries are educated on what benefits they have and put the responsibility on the plan to notify beneficiaries when they are not using them. The notice would be sent by the plan sponsor mid-year to beneficiaries who have unused supplemental benefits in Q1 and Q2.

Special Supplemental Benefits for the Chronically Ill (SSBCI) are also identified in the CY 2025 Proposed Rule for additional operational requirements. It is important to remember that while these benefits may be attractive to your full membership, they are only available for those who meet specific chronic conditions and will benefit from improved or maintenance of their health.  Aligning with that, CMS is proposing that plan sponsors develop evidence in the form of a bibliography that the item or services offered has a reasonable expectation of doing so. It will no longer be enough to assume a beneficiary is eligible and afford them the benefit. Plan sponsors would be required to document evidence of any denials of eligibility.  As a best practice, plan sponsors should continue to document approvals. If approved, we should also expect to see new policies and marketing requirements from CMS around SSBCI.  The seriousness of administering this benefit must be recognized as CMS proposes going as far as denying a plan sponsors bid if they feel the plan has not demonstrated effective processes and policies to offer SSBCI. While the rule may only be proposed, plans should be considering these changes now to make sure they will be prepared to implement if these changes move to final.