Institutional Special Needs Plans (I-SNPs)

Institutional Special Needs plans restrict enrollment to Medicare Advantage (MA) eligible individuals who, for 90 days or longer, require 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 (ICF) for the developmentally disabled n inpatient psychiatric facility, or an assisted living facility (ALF). I-SNPs may also enroll MA eligible individuals living in the community, but requiring an institutional level of care, known as Institutional Equivalent SNPs. When an I-SNP opts to enroll individuals prior to having at least 90 days of institutional level care, a CMS-approved needs-assessment must be conducted.  Results of the assessment must demonstrate that the individual’s condition makes it likely that either the length of stay or the need for an institutional level-of-care will be at least 90 days.

Please visit the following sections for more information on I-SNPs:

Long Term Care Facility Contract Requirements

I-SNPs that serve residents of LTC facilities must own, operate, or have a contractual arrangement with the LTC facility that includes adherence to its approved I-SNP Model of Care (MOC). Contract requirements are as follows:

  1. Facilities in a chain organization must be contracted to adhere to the I-SNP MOC
  2. Facilities must provide access to I-SNP clinical staff
  3. Facilities must provide protocols for the I-SNP MOC
  4. Delineation of services provided by the I-SNP staff and the LTC facility staff must be specified
  5. Training plan for LTC facility staff to understand the MOC must be included
  6. Procedures must be developed and in place for facilities to maintain a list of credentialed I-SNP clinical staff
  7. Contract year for I-SNP must be specified
  8. Grounds for early termination and transition plan for beneficiaries enrolled in the I-SNP must be specified

For more information on LTC facility contract requirements, please visit the MMCM Chapter 16b, section 40.6 and SNP FAQ accessible in the Download section below.

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Level of Care Assessment for Institutional Equivalent Special Needs Plans

I-SNPs that are designated for individuals living in the community and requiring an institutional level of care (LOC) may only enroll individuals who have been determined to need an institutional LOC. These I-SNPs must submit the following information to CMS via the Health Plan Management System (HPMS) as part of the SNP application:

  1. The 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, SNPs must use the same LOC determination methodology used in the respective State or territory in which the SNP is authorized to enroll eligible beneficiaries.

  1. The name of the entity performing the assessment

    The assessment mustbe performed by an entity unrelated to the MA organization offering the I-SNP with the requisite professional knowledge to accurately identify institutional LOC needs. This independent party should be an independent contractor or grantee. In addition, the independent party should not receive any kind of incentive for qualifying members for the SNP.

Applications for this type of I-SNP are reviewed on a case-by-case basis for approval during the annual MA application cycle.

For more information on the LOC assessment, please visit section 1859(f)(2) of the Social Security Act, MMCM Chapter 16b, sections 20.3.2 and 50.2.2 and the SNP FAQ accessible in the Download section.

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Service Area Requirements and Change of Residence

CMS may allow an I-SNP to establish a county-based service area as long as it has at least one LTC facility that can accept enrollment and is accessible to the county residents.

If an I-SNP enrollee changes residence, the SNP must document that it is prepared to implement a CMS-approved MOC at the enrollee's new residence in another institution, or in another setting that provides an institutional level of care, as long as the enrollee still resides within the I-SNP’s service area.  If the MA organization operating the I-SNP did not submit MOCs for the type of residence in which the enrollee is relocating, such as an LTC facility, the MA organization is required to give the beneficiary the option to disenroll.

For more information on service area requirements, please visit the following documents accessible from the Download section: (i) MMCM, chap. 16b, section 40.4.1 and (ii) the SNP FAQ. For more information on change of residency, please visit the MMCM chapter 16b, section 20.3.3 accessible in the Download section below.

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I-SNP Marketing

In addition to the general marketing guidelines that all MA organizations must follow, I-SNP marketing materials and outreach for new enrollees must clearly indicate that enrollment is limited to those beneficiaries who live in, or are willing to move to, contracted LTC facilities.

For more information on general marketing guidelines and other I-SNP marketing policies, please visit the MMCM Chapter 3 and the SNP FAQ accessible in the Download section below.

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