The hallmark of the institutional special needs plan (I-SNP) model is proactive, preventive, person-centered primary care provided by advanced practice professionals such as nurse practitioners in long term care facilities, where seniors reside. The ability to design a model of care tailored to the needs of long term care (LTC) beneficiaries—thereby delivering the right care at the right time in the right setting, reducing avoidable hospitalizations—makes the I-SNP an attractive alternative to traditional Medicare Advantage (MA) plans.

Provider-led I-SNPs continue to grow as LTC providers look to assume full responsibility for the health and outcomes of their residents and meaningfully participate in value-based care. I-SNPs, by design, restrict enrollment to only individuals who reside in a skilled nursing facility (SNF), a nursing facility (NF), an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility.

The Institutional Equivalent Special Needs Plan

For providers looking to extend the benefits of the I-SNP model to residents beyond the long term care facility, an institutional equivalent special needs plan (IE-SNP) provides the pathway. The IE-SNP’s model of care, flexibility, and services are very similar to an I-SNP’s; the main difference is where the plan members reside. IE-SNPs are available to beneficiaries who meet the state definition for institutional level of care but aren’t in an LTC facility. This includes those residing in assisted living (AL), memory care (MC) communities, and even independent living and private homes.

“Increased membership potential explains part of the push into IE-SNPs, but IE-SNPs are also a way to extend a plan’s model of care and supportive services,” said Amy Kaszak, executive vice president of strategic initiatives at Curana Health. “For example, an LTC provider who also operates AL or MC facilities may offer an IE-SNP to AL/MC residents, so they have access to additional care coordination and preventive services provided through existing I-SNP providers and infrastructure. The AL and MC communities benefit from a potentially longer length of stay for plan members who—through preventive care and use of skill-in-place services—require fewer hospitalizations and are able to live in AL/MC communities safely for a longer period of time.”

Steve Fogg, chief financial officer at Marquis Companies and Consonus Healthcare, said, “We entered the IE-SNP space to offer a plan design that gave us the ability to better meet the needs of our non-dual-eligible population in our AL facilities. We happen to operate a plan that has a tangible number of members that reside in non-SNF settings, such as an AL facility or MC. We offered some additional benefits in the over-the-counter/medical supplies area, increased the maximum allowable benefit for dental, and heightened non-emergent transportation benefits. We did all of this with only a $1 per month increase in monthly premium to the member, compared to our I-SNP.”

Other providers see offering an IE-SNP to Medicare beneficiaries with complex, chronic conditions as a way to build a trusted relationship with potential residents. Many providers own home health, personal care, and therapy lines of business, which can be used to support an IE-SNP model of care outside of an LTC facility.
“From a business standpoint, this enables them to take the I-SNP model and expand it out into other settings,” said Fred Bentley, managing director at ATI Advisory. “More importantly, IE-SNP participants benefit from the plan because there are customized offerings that they wouldn’t get from a regular MA plan.”

Kaszak explained, “For LTC provider-owned or provider-led plans, IE-SNPs may also allow LTC providers to leverage existing resources, such as home health companies or primary care relationships, which can improve the model of care and resident outcomes for AL, MC, and independent living residents, and can be a way for LTC providers to begin to provide more services in the community at large.”

Potential Challenges for IE-SNPs

Since IE-SNPs primarily target senior living residents, many of whom are Medicare beneficiaries, residents are less inclined to enroll in MA plans. “Enrollment tends to be more challenging for this population to see a compelling offer and switch out of their Medicare fee-for-service care. If enrollment is low, you can’t deliver on the product,” Bentley said.

Medical management is another challenge for IE-SNPs. AL residents’ preferred network and eligibility do not depend on members’ residing in contracted facilities, so residents are more likely to continue seeing specialists with whom they have established relationships.

“Providers with I-SNPs who expand to an IE-SNP may find that they need to add new ‘preferred’ network providers to their panels. While all MA plans have the same CMS [Centers for Medicare & Medicaid Services] network adequacy requirements, Medicare beneficiaries living outside of a SNF most likely will want to access a different set of primary care doctors and sometimes even different specialist groups than their SNF counterparts,” Kaszak said. “Contracting with these ‘preferred’ providers may be important for plan membership.”

Despite these hurdles, IE-SNP plans and enrollment are projected to grow. Provider-led plans will continue to evolve to best meet the needs of their residents. IE-SNP providers are optimistic about the future and encourage physicians in the fee-for-service realm to partner with provider-led plans to enhance the quality of care and outcomes for beneficiaries.

Natalie Visnick is senior manager of public affairs for the American Health Care Association.