According to the CMS, Institutional Special Needs Plans (I-SNPs) restrict enrollment to Medicare Advantage (MA) eligible individuals who, for 90 days or longer, have had or are expected to need the degree of services provided in a:
- Long-term care (LTC)
- Skilled nursing facility (SNF)
- LTC nursing facility (NF)
- SNF/NF
- An intermediate care facility for individuals with intellectual disabilities (ICF/IDD)
- An inpatient psychiatric facility
Qualifying for an I-SNP
Now, saying “if you need long-term care, you are eligible” is far too broad to be understood. Then, you should understand what conditions are qualifications for long-term care and what’s then covered under an I-SNP.
There are a few factors that may bring up the need for long-term care, including:
- Age: Your potential need for long-term care increases as you age.
- Gender: Women are statistically at a higher risk for conditions requiring long-term care.
- Marital Status: Single people are more likely to need paid medical care than married people because they may not be able to care for themselves.
- Sudden Injuries: If you experience a sudden injury such as a serious fall or heart attack, you may need long-term care.
- Lifestyle and Habits: If you live or used to live an unhealthy lifestyle with a poor diet, lack of exercise, smoking, etc., you are more likely to need long-term care.
- Health and Family History: If you or family members have a history with serious medical issues, you’re more likely to need long-term care as you age.
- Current Health Condition(s): Current health problems can change or worsen suddenly/over time. In that case, you may need long-term care for treatment.
Choosing a Long-Term Care Facility for Your I-SNP
You can apply for an I-SNP before residing in an institution for 90 days if you complete a CMS-approved needs assessment. Or, if you have already been in an institution for 90 days, but it’s not accepted under your I-SNP, you’ll want to find an approved Long-Term Care (LTC) facility to reside in.
According to the CMS, the facility you are residing in must meet these 8 requirements:
- Facilities in a chain organization must be contracted to adhere to the MOC.
- Facilities must provide access to clinical staff.
- Facilities must provide protocols for the MOC.
- Specifically portray services provided by the I-SNP staff and the LTC facility staff.
- Training plans for LTC facility staff to understand the MOC must be included.
- Procedures must be developed and in place.
- Contract year for I-SNP must be specified.
- Grounds for early termination and transition plan for beneficiaries enrolled in the I-SNP must be specified.
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