Institutional Special Needs Plans

Happy senior grandmother using video call to discuss Institutional Special Needs Plan.

Approximately 2 million Americans on Medicare live in long term care facilities. Institutional Special Needs Plans (ISNPs) are designed to help provide comprehensive care while adding financial protection for Medicare beneficiaries. Apart from living in long term care facilities, many people on Medicare will have shorter term stays in skilled nursing facilities as they recover from various illnesses and accidents. While Medicare will not pay for custodial care in a long term care setting, it does pay for ongoing medical expenses while you stay in one. However, the unique medical needs of residents in long term care or other institutional facilities often make comprehensive and quality care difficult. Plus, the cost of staying in a long term care facility may make medical care unaffordable. In this article, we’ll review some of the basics of these unique plans.

What Are Institutional Special Needs Plans (ISNPs)?

For starters, it’s important to know that ISNPs are a type of Medicare Advantage plan. A Medicare Advantage plan is a contract between CMS (Centers for Medicare and Medicaid Services) and an insurance company. The contract spells out all the services and procedures covered, as well as the costs you will pay for them. In this way, a Medicare Advantage plan covers everything covered by Original Medicare – Parts A and B. ISNPs are a special subset of Medicare Advantage plan called Special Needs Plans. Special Needs Plans are designed to meet the needs of special Medicare populations. The other two types of Special Needs Plans are for people who are dually eligible for both Medicare and Medicaid, and for people with certain chronic health conditions.

As the name implies, Institutional Special Needs Plans are designed for people who are expected to need an institutional level of care for at least 90 days. There is some flexibility here, but generally you need to receive a level of care typical of:

  • Skilled nursing facilities
  • Long term nursing facilities
  • Intermediate care facility
  • Inpatient psychiatric care facility

In many cases, the plan member will live or stay in these kinds of facilities, but it is possible for people who live independently, but need this level of care, to qualify for enrollment in an ISNP.

So, Institutional Special Needs Plans (ISNPs) are Medicare Advantage plans designed to help people who either live in, stay in, or require the level of care provided in, an institutional facility.

These specialized Medicare Advantage plans are optimized to help care for the needs of long term care residents. To facilitate this, these plans utilize a ton of “coordination.” All aspects of your care are coordinated. The goal in doing this is to make sure that all of your health needs are met. This is especially important because so many people who need an institutional level of care have multiple chronic illnesses. With various specialists involved in your care, sometimes the “whole you” gets lost in the shuffle. With an ISNP, this is less likely to happen. Instead, your care coordinator will work with all the medical professionals who care for you.

In addition, with ISNPs, there is a greater usage of Registered Nurses than normal. These professionals are the ones who regularly interact with residents and patients, and as skilled medical professionals, they’re able to implement the total care plan designed for them. Besides the generic goal of improving the care of people in institutional settings, a major goal is to reduce the number and frequency of hospitalizations. By working as a team with one coordinated care plan, ISNPs are able to attain this goal.

Seniors holding hands and walking as they discuss their medicare plan that has Institutional Special Needs Plan in it.
In addition, with ISNPs, there is a greater usage of Registered Nurses than normal.

Special Eligibility Rules For ISNPs

Besides the requirement to need institutional-level care for 90 or more days, Institutional Special Needs Plans have one other unique enrollment feature. People who live in or are released from a long term care facility have a standing Special Enrollment Period (SEP). This SEP allows them to make changes to their Medicare plan coverage. When you qualify for this SEP, you can make any of the following changes:

  • Enroll in a Medicare Advantage Plan (leave Original Medicare)
  • Switch from one Medicare Advantage Plan to another
  • Drop Medicare Advantage and return to Original Medicare
  • Switch or choose a standalone Part D Drug plan, based on your other enrollment changes

Here’s the most valuable thing about this SEP – it’s not a one-time only choice. You can continue to make changes to your coverage for as long as you’re a resident of the facility. Any time you make a change in coverage, it will be effective on the first day of the month after you enroll. If you’re discharged from the facility, or choose to move out, you’ll have two extra months to change plans.

Using this institutional facility SEP is how you can enroll in an ISNP in the first place. If for some reason it doesn’t meet your needs, you can switch plans at any time due to the standing SEP. This is a very valuable benefit; no other SEP stays available as long.

Note that your enrollment in an Institutional Special Needs Plan is voluntary. Just because you live or stay in a long term care facility for 90 days or longer doesn’t mean you must enroll in an ISNP. In fact, if you already have Medicare Supplement Insurance (Medigap), you probably won’t want to enroll in an ISNP.

How To Find Out More About ISNPs

If you’re interested in enrolling in an ISNP, working with an independent health insurance agent is a great way to get the information you need to choose a plan. An independent agent can help you compare the benefits of several plans to see which one would suit you. Also, agents can look up your doctors, other providers, as well as your medications to see if they’re covered by the plans available in your area. This is especially useful since you have that standing Special Election Period – if for some reason one plan isn’t working for you, you can easily switch to a new one. You can even choose to switch to a standard, non-ISNP Medicare Advantage plan if that was to your benefit.

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