By Marc Gilman
Questions? Call (800) 927-9326 or email
Key Takeaways
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CMS terminated the Value-Based Insurance Design (VBID) model after 2025, citing billions of dollars in costs the program wasn’t controlling as intended — $2.3 billion in 2021 and $2.2 billion in 2022 alone, according to CMS’s own evaluation.
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VBID is what let many Medicare Advantage plans offer perks like monthly credits for healthy food and utility bills, and in some cases, $0 copays on prescription drugs for enrollees who qualify for Extra Help.
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The replacement pathway, Special Supplemental Benefits for the Chronically Ill (SSBCI), only allows these benefits for enrollees who meet a federal definition of chronically ill — a real, and for some people new, eligibility bar.
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The $0 prescription drug copay perk does not carry over to SSBCI at all — this is the single biggest disruption for people used to that benefit under VBID.
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If your plan offered food, utility, or $0 Rx benefits in 2025, read your Annual Notice of Change (ANOC) letter closely this fall — some benefits may now require documented proof of a qualifying chronic condition, or may not be offered at all in 2026.
What Was VBID, and Why Did CMS End It?
The Value-Based Insurance Design model, created by CMS in 2017, let Medicare Advantage plans offer non-medical supplemental benefits — things like food assistance, utility bill credits, and housing support — often targeted at enrollees with low incomes or in underserved areas. It also allowed plans to offer $0 cost-sharing on prescription drugs as an incentive, in some cases for enrollees who qualify for the Extra Help program.
CMS terminated the model after 2025. The stated reason is stark: according to CMS’s own evaluation, VBID generated $2.3 billion in excess costs to the Medicare Trust Funds in 2021 and $2.2 billion in 2022 — costs CMS said it could not address through policy adjustments alone.
What Replaces It: SSBCI
CMS is directing insurers toward a different, already-existing pathway: Special Supplemental Benefits for the Chronically Ill (SSBCI), created by the Bipartisan Budget Act of 2018. SSBCI allows Medicare Advantage plans to offer many of the same categories of non-medical benefit — food, transportation, some utility support — but with a meaningfully different eligibility structure.
SSBCI benefits can only go to enrollees who meet a federal definition of “chronically ill”: someone with one or more comorbid, medically complex chronic conditions that are life-threatening or significantly limit their health or function, and who has a high risk of hospitalization or other adverse health outcomes. That’s a real clinical bar — not simply “having a chronic condition” in a general sense, and in some cases plans may require documentation to confirm it.
The Biggest Disruption: $0 Prescription Copays
This is the change most likely to catch people off guard. SSBCI does not permit $0 cost-sharing for prescription drugs — a benefit some VBID plans offered, particularly for Extra Help-eligible enrollees. If your 2025 plan included this perk, expect it to end or change materially for 2026, regardless of your chronic illness status. This isn’t a chronic-illness eligibility issue — it’s a hard rule that SSBCI simply doesn’t cover this benefit category at all.
What Benefits Are Actually Affected?
Based on what CMS and insurers have described heading into 2026:
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Healthy food and grocery credits — now generally require SSBCI’s chronic-illness qualification
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Utility bill assistance — same shift, now tied to chronic-illness status
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OTC (over-the-counter) allowances — may or may not require chronic-illness qualification depending on how a specific plan structures the benefit; some plans combine OTC with food into a single SSBCI-qualified credit, while offering a separate, broader OTC-only benefit to their full membership
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$0 Part D prescription copays — not available under SSBCI at all, full stop
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Home-delivered meals and non-medical transportation — may continue as standard supplemental benefits for the general membership, separate from the more restrictive SSBCI category, though some plans offer expanded versions of these specifically through SSBCI for qualifying members
CMS also finalized new guardrails for 2026 limiting what can be offered as SSBCI even for chronically ill enrollees — meaning even the expanded category has real limits on what qualifies.
Who Actually Still Qualifies?
If you’re already enrolled in a Special Needs Plan — a Chronic Condition SNP (C-SNP) or Dual Eligible SNP (D-SNP) — you likely already meet a qualifying chronic-illness standard simply by virtue of your plan’s own enrollment requirements, since those plans are restricted to people with specific conditions or dual Medicare/Medicaid status to begin with. For those enrollees, the practical disruption from this shift may be minimal.
The bigger risk is for people on a standard Medicare Advantage plan who received VBID-based food, utility, or Rx benefits in 2025 without a specific chronic-illness qualification — that population is the most likely to see real changes for 2026.
What Should You Actually Do?
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Read your Annual Notice of Change (ANOC) letter carefully this fall, before the Annual Enrollment Period begins October 15 — this is where your plan is required to disclose benefit changes for the coming year.
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If you relied on a $0 Part D copay benefit, budget for that changing regardless of your health status — this one isn’t a chronic-illness eligibility question.
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If you have a legitimate qualifying chronic condition and lost a food or utility benefit, ask your plan directly whether SSBCI documentation could restore it — it may just require updated paperwork from your provider.
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If your benefits changed enough to matter, this is also a good moment to compare plans during Annual Enrollment rather than assuming your current plan is still the best fit.
What To Do Next
This is a genuinely significant shift affecting Medicare Advantage supplemental benefits nationally for 2026 — not a plan-specific quirk, but a federal policy change with real financial reasoning behind it. If your ANOC letter shows changes you don’t understand, or you’re not sure whether you’d qualify for SSBCI-based benefits going forward, it’s worth a conversation before Annual Enrollment closes.
Reach out and we’ll walk through what changed on your specific plan.
Questions? Call (800) 927-9326 or email
