Institutional Special Needs (I-SNP)

Understanding Your Institutional Special Needs Plan (I-SNP)

in a Skilled Nursing Facility (SNF) 

What Is an Institutional Special Needs Plan (I-SNP)?

An Institutional Special Needs Plan (I-SNP) is a type of Medicare Advantage plan (also known as Part C), specifically designed for individuals who reside in a skilled nursing facility (SNF) for long term care.

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, hospice and some home health care.
• Part B (Medical Insurance): Covers doctor visits, outpatient services, therapies, and medical services.
• Medicare Part D: Includes prescription drug coverage.
• Additional Benefits often include: Dental, vision, OTC (Over-the-counter) spending benefits, transportation and more. 

Because Institutional Special Needs plans are managed by private insurers, they operate with specific coverage rules and provider networks.

1. Prior Authorization
   Institutional Special Needs Plans (I-SNPs) are specifically designed for individuals who already reside in a skilled nursing facility (SNF). 
   • Prior authorization is still required for many specific medical services including: therapies, tests, and medical equipment. 
2. Costs and Coverage

• Days 1–100:  Covered by your Institutional Special Needs Plan.
• After Day 100: As long as you qualify for long-term institutional care coverage, then you meet the necessary criteria for long term care services.

1. Prescription Drug Coverage

• All medications administered at the facility are covered by Medicare Part A. 

 Your Options: 

1. Switch to Original Medicare (upon return to the community) 

• • Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing care, and some home health care. Deductibles and copays apply.
    • If you have Medicaid: Medicaid will cover the deductibles and copays in the hospital.
  • Part B (Medical Insurance): Covers doctor visits, therapies, and medical services. Non-preventative services covered up to 80%
    • If you have Medicaid: Medicaid will cover the remaining 20% coinsurance. 
  • Prior authorizations are not required. With Original Medicare, there are no prior authorization requirements for all Medicare approved services including therapies, tests, medical equipment and length of stay at the Skilled Nursing Facility, should you return.

• Original Medicare gives up to 100 days for skilled nursing care.

• • • Length of stay is determined based on your medical needs and the interdisciplinary team at the facility. 
    • Days 1–20: Fully covered by Medicare
    • Days 21–100: $209.50 daily copay.
      • $0 copay, if you have Qualified Medicare Beneficiary (QMB) Medicaid or Nursing Home Medicaid. 

• After Day 100: You’re responsible for the full cost. 

• • • • $0 if you have Nursing Home Medicaid. 

• Next Steps:

• • Enroll in a Medicare Part D drug plan to disenroll your Medicare Advantage plan. 
  • Medications will be covered by your Part D drug plan post your skilled nursing care stay. 
  • Consider adding a Medicare Supplement plan to help with out-of-pocket costs.
    • If you have Medicaid: Medicaid will cover these costs.

2. Switch to a Medicare Advantage plan

• • Medicare Advantage Plan: You can switch to a Medicare Advantage plan, which includes prescription drug coverage (Part D), and additional benefits like hearing, vision, and dental.*

• Dual Medicare Advantage Plan: You can switch to a Dual Medicare Advantage plan if you have Medicaid. This will include prescription drug coverage (Part D) and additional benefits like hearing, vision, dental, transportation, and OTC (Over-the-Counter) Credit.*

*You qualify for a Special Enrollment Period (SEP) to make plan changes. Changes can be made for as long as you are in the facility and for an additional two months after the month you leave the facility.