In 2018, the Bipartisan Budget Act authorized Medicare Advantage Plans to provide more supplemental benefits to enrollees suffering from chronic illnesses. Specifically, Advantage plans were given authorization to cover Special Supplemental Benefits for the Chronically Ill (SSBCI). CMS classifies these as "non-primarily health-related" benefits, yet requires that they must still be "reasonably expected to improve or maintain the health or function" of the chronic illness sufferer. CMS is now imposing new limits on some of these services in 2026 to restrict the kinds of coverage that are allowed.
Items No Longer Covered in 2026
CMS has codified a list of specific items and services that Medicare Advantage plans are strictly prohibited from covering. These include:
Recreational Substances: Alcohol, cannabis, and tobacco products.
Lifestyle & Personal Finance: Funeral costs, life insurance, and hospital indemnity insurance.
Cosmetic Services: Procedures solely for appearance, such as facelifts, treatment for facial lines, or fat/collagen atrophy treatments.
Unhealthy Foods: While some plans still offer grocery allowances, these funds cannot be used for "unhealthy" food options (generally excluding high-sugar snacks, sodas, and chips).
Broad Membership Programs: Programs that offer a bundle of unrelated services or general discounts that aren't tied to a specific health outcome.
Non-Food Essentials (under Grocery Benefits): Prior to 2026, enrollees who could not afford household essentials often used their cards for toilet paper, paper towels, and cleaning supplies. These "General Supports for Living" are now restricted and can no longer be bundled into grocery allowances.
New Restrictions on Transportation & Home Fixes
For 2026, CMS is also narrowing "non-medical" supports that were previously more flexible:
Transportation: Routine rides are being significantly scaled back. Many plans have reduced the number of covered trips, and destination rules are tighter. Rides are generally limited to plan-approved "health-related" locations (medical visits and pharmacies) rather than general errands such as the grocery store or social trips.
Home Modifications: Permanent structural changes to a home—such as widening hallways or installing permanent ramps—now face higher scrutiny. Plans must strictly document that these modifications are a medical necessity to treat the specific chronic condition and are not general home improvements.
New Restrictions on "Special" Benefits
One of the biggest shifts in 2026 involves these Special Supplemental Benefits for the Chronically Ill (SSBCI), which includes popular perks like grocery allowances and utility assistance.
Strict Eligibility: You must have a verified qualifying chronic condition (such as diabetes, chronic heart failure, or certain mental health conditions).
Medical Necessity: Plans must now demonstrate that these benefits have a "reasonable expectation" of improving or maintaining your health.
End of VBID Model: The "Value-Based Insurance Design" model, which previously allowed plans to offer these perks more broadly to help those who couldn't afford them, is ending.
The 15 Qualifying Chronic Conditions
To access remaining SSBCI benefits, CMS requires documentation of at least one of these 15 core conditions:
Chronic Heart Failure, Diabetes Mellitus, Cardiovascular Disorders, Chronic Lung Disorders, Chronic and Disabling Mental Health Conditions, Neurologic Disorders, Autoimmune Disorders, Cancer, Dementia, Chronic Kidney Disease, HIV/AIDS, Severe Hematologic Disorders, Chronic Alcohol and Other Drug Dependence, End-Stage Liver Disease, and Stroke.
Key Verification & Filtering Rules
Provider Attestation: Plans must obtain a signed form or diagnosis code from your treating physician.
Risk Assessment: Enrollees must be documented as "high risk" for hospitalization.
Real-Time Filtering: Plans must use "item-level" electronic filtering at the register to automatically reject prohibited items (like alcohol, tobacco, and unhealthy snacks) in real-time.
2026 Out-of-Pocket Limits
Medical Out-of-Pocket Cap: The federal maximum limit for in-network medical services is $9,250 in 2026. Note that most individual plans set their specific limits lower.
The $2,100 Drug Cap: A major change for 2026 is the $2,100 annual cap on out-of-pocket prescription drug costs. Once you spend $2,100 on covered drugs at the pharmacy, you pay $0 for the rest of the year.
Local Workarounds for 2026 Transit Cuts
While federal Medicare Advantage rules are tightening, several state and locally funded programs in Western North Carolina still provide non-medical transportation for grocery shopping and errands:
Mountain Mobility (Buncombe County): 828-250-6750 (Option 5). Offers Community Service Routes for grocery shopping and a "RIDE" voucher program where seniors can buy $10 trip vouchers for $2.50.
Mountain Projects (Haywood & Jackson Counties): 828-565-0362. Provides Haywood Public Transit for demand-response shopping trips.
Council on Aging (Buncombe County): 828-277-8288. Operates "Call-A-Ride," a volunteer-based program for grocery and essential non-medical trips.
Vaya Health (Regional): 888-621-2084. Certain Medicaid plans through Vaya may cover up to 12 non-medical round-trips per year to grocery stores.
Senior Bus Pass (Asheville): Seniors age 65+ can obtain a free monthly ART bus pass through Mountain Mobility (828-250-6750, Option 5) for flexible travel.
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