Institutional Special Needs Plans (I-SNPs) are SNPs that restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility. A complete list of acceptable types of institutions can be found in the Medicare Advantage Enrollment and Disenrollment Guidance, which is located at the link below.
CMS may allow an I-SNP that operates either single or multiple facilities to establish a county-based service area as long as it has at least one long-term care facility that can accept enrollment and is accessible to the county residents. As with all MA plans, CMS will monitor the plan’s marketing/enrollment practices and long-term care facility contracts to confirm that there is no discriminatory impact.
Institutional Equivalent SNPs
For an I-SNP to enroll MA eligible individuals living in the community, but requiring an institutional level of care (LOC), the following two conditions must be met:
- A determination of institutional LOC that is based on the use of a state assessment tool. The assessment tool used for persons living in the community must be the same as that used for individuals residing in an institution. In states and territories without a specific tool, I-SNPs must use the same LOC determination methodology used in the respective state or territory in which the I-SNP is authorized to enroll eligible individuals.
- The I-SNP must arrange to have the LOC assessment administered by an independent, impartial party (i.e., an entity other than the respective I-SNP) with the requisite professional knowledge to identify accurately the institutional LOC needs. Importantly, the I-SNP cannot own or control the entity.
Change of Residence Requirement for I-SNPs
If an I-SNP enrollee changes residence, the I-SNP must document that it is prepared to implement a CMS-approved MOC at the enrollee’s new residence, or in another I-SNP contracted LTC setting that provides an institutional level of care.