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Institutional Special Needs Programs (I-SNPs) and advancing the care continuum in senior living

The Senior Advisor: Season 1, Episode 1

May 11, 2023

A podcast series on issues facing the senior living industry, exploring risk management solutions and hot topics critical to senior living operations.

In the first episode of The Senior Advisor, host Rhonda DeMeno welcomes Cheryl Phillips, President and CEO of the SNP Alliance and Amy Kaszak, EVP of Strategic Initiatives for Curana Health, to the show to address Medicare Advantage Institutional Special Needs Plans (I-SNPs). This episode focuses on defining SNPs: what they are, what they do and how they inter-related to senior living and long-term care.

The Senior Advisor: Season 1, Episode 1: Institutional Special Needs Programs

Transcript for this episode:

The Senior Advisor — Episode 1: Institutional Special Needs Programs (I-SNPs) advancing the care continuum in senior living

CHERYL PHILLIPS: The biggest marketing tool for I-SNPs is not the pamphlets. It's not flyers. It's the fact that, hey, how come my mom's roommate gets this really nice nurse practitioner that comes and see her every time she doesn't feel well, and my dad doesn't get that? How come?

SPEAKER: You're listening to The Senior Advisor, a WTW podcast series where we'll discuss issues facing the senior living industry and explore risk management solutions, hot topics, and important trends critical to senior living operations.

The biggest marketing took for I-SNPs is not the pamphlets… it’s the ‘hey, my mom gets a nice nurse practitioner when she doesn’t feel good, but my dad doesn’t get that… how come?”

Cheryl Phillips | President and CEO of the SNP Alliance

RHONDA DEMENO: Welcome to The Senior Advisor podcast. My name is Rhonda DeMeno, and I am thrilled to be your host today. This podcast series is intended to bring you firsthand information on trends and hot topics facing the senior living industry. Today's episode will introduce the concept of Medicare Advantage Special Needs Plan and provide guidance to senior living long term care operators on special needs plan.

This podcast is titled, I-SNP Advancing the Care Continuum in Senior Living. This podcast will concentrate on defining special needs programs, what they are, what they do, and how they interrelate to senior living and long-term care.

I'm pleased to introduce you to our distinguished panelists today. We have Amy Kaszak. Amy is an executive vice president of Strategic Initiatives for Curana Health. Today, Amy leads AllyAlign Health fully owned Align Senior Care Branded Plans, which include I-SNPs, C-SNPs, and MAPD or Medicare Prescription Drug Plan. So welcome, Amy. We're so excited to have you with us today.

AMY KASZAK: I am looking forward to this conversation. So, thank you so much for including me.

RHONDA DEMENO: We also have Dr. Cheryl Phillips. Dr. Phillips is the president and CEO of the SNP Alliance. Cheryl is a medical doctor, is the president and CEO of the Special Needs Plan Alliance, a national leadership association for special needs and Medicare Medicaid plan, serving vulnerable adults. Happy to have you join us today.

CHERYL PHILLIPS: Oh, thank you, Rhonda. You can tell I am enthusiastic ambassador for I-SNPs, so it's my honor. Thank you.

RHONDA DEMENO: Cheryl, can you clearly define what special needs programs are?

CHERYL PHILLIPS: So special needs plans or SNPs as they're called. My family thought that I was moving into cosmetology and hairdressing when I told them I was going to run the SNP Association. And yes, SNPs have nothing to do with haircuts or vasectomies. What they are, are special needs plans as a subset of Medicare Advantage.

Medicare Advantage, for those of you that are familiar, is often referred to as Medicare Managed Care, Medicare HMOs. We've had lots of terms for them over the years. But special needs plans are a subset of those. They were first authorized by Congress in 2003 and started enrolling individuals in 2006.

So, let's get to a little bit more of what they are. There are three types. The largest one, right now representing about 4 and 1/2 million enrolled individuals, are those who are duly eligible for Medicare and Medicaid. The second largest type are C-SNPs for chronic conditions or chronic illness. These are individuals who have a diagnosis of a serious or potentially life-threatening chronic condition as deemed by CMS because, of course, everything is deemed by CMS.

So, there are 17 disease categories or groupings of categories. And you can imagine what they might be. Stroke and the serious consequences afterwards. Cancer diagnoses, serious heart disease, lung disease, progressive neurologic disorders, diabetes with complications. You can think through of what these chronic conditions might be. There's about 400,000 individuals enrolled in those.

And then the third one and I think one we'll probably talk the most about are institutional or I-SNPs or now, IE-SNPs, Institutional Equivalent SNPs. These special needs plans are for individuals who have been determined to be at a nursing home level of care for at least 90 days, and that determination by the state in which the plan is providing.

But they don't have to be in the nursing home. In order to be in a special needs plan, you have to be eligible for Medicare A and B, and you have to be selecting a managed care product. So, this is not fee for service Medicare. It's a Medicare Advantage subset.

But if you think of Medicare Advantage with the overriding-- roughly 50% of people are now enrolled in Medicare Advantage. These are a subset of plans under Medicare Advantage. And again, D-SNPs for duals, C-SNPs for chronic condition, and I-SNPs for institutional level of care individuals.

We've touched a little bit about what's a difference between all of the SNPs and an I-SNP. The I-SNP is focusing on that which is specific to an institutional level of care. But remember, they don't have to physically be in the nursing home. And I'm going to turn over to Amy now because you can probably tell I would talk for another 20 minutes.

RHONDA DEMENO: Amy, is there anything that you want to add to what Cheryl's definition was? And maybe, could you elaborate a little bit more on these special needs’ programs and the difference between special needs and institutional special needs program? Can you provide a little more clarity on that?

AMY KASZAK: Well, sure. So, Cheryl did a great job of giving some of the history of Medicare Advantage Special Needs Plans. I think one of the first questions I usually get asked about special needs programs and I-SNPs in particular are, are they full Medicare plans? And the answer is yes.

Special needs plans are a, quote, full Medicare Advantage, meaning that they cover all Part A services. They cover all Medicare Part B services. And special needs plans are required to also cover Part D services. So yes. All special needs plans including I-SNPs are a, quote, complete Medicare Advantage plan. I-SNPs are a subset of special needs plans overall.

They are similar to the C-SNPs and the D-SNPs in that they represent a smaller subset of the overall Medicare beneficiary population. And the only thing that is different about the SNPs, we're not paid any differently than other Medicare Advantage plans. What makes them different is, first of all, the eligibility requirements. So again, for I-SNPs or IE-SNPs, you have to meet that institutional level of care.

And so, there's different eligibility requirements. And then also, we won't get into all of this right now, but there's also some allowances around enrollment periods, for example, and some special enrollment periods because people who are eligible for these special needs’ plans might become eligible in the middle of a calendar year, for example.

So, there's a little bit more flexibility sometimes around when eligible seniors can enroll in these plans and also when they can dis-enroll or switch out of these plans. So, I would just add that to the overall special needs plan definition. But otherwise, they function very much like Medicare Advantage.

The other really important thing I think from my perspective is for special needs plans. When Medicare set these up back with the MMA in 2003, the Medicare Modernization Act of 2003, they said, hey, if you're going to be taking care of special populations, you need to have a special model of care. So, if you are in discussions with Medicare Advantage plans, specifically SNPs, we're always going to want to tell you about our model of care. And we'll talk a little bit more about why that's important and how it might impact your senior living organization.

RHONDA DEMENO: So, you mentioned eligibility. So, for the I-SNP, a resident has to be in a skilled nursing center for 90 days to qualify?

CHERYL PHILLIPS: No. And to clarify again, you have to be at the state-determined nursing home level of care. But you may be living in assisted living. You may be living in the community. And I think that where Amy opened up the model of care discussion, one of the things that's very distinctive about a special needs plan is this model of care.

This model of care says who am I going to take care of? How am I going to take care of them? What is the team makeup that is going to be used to take care of them? How am I going to measure the impact of what I'm doing? How am I going to train the providers? There's this whole array of key elements that has to be approved, and we won't get into all of the alphabet soup of the oversight processes, but these models of care have to be approved.

So, if I am starting up an I-SNP or I am partnering with other organizations to open up a Medicare Advantage plan I-SNP, the eligibility for the people that I would enroll are that they are at a nursing home level of care. But in my model of care, I'm going to say, am I going to target my enrollment on a nursing home setting, or am I going to look at an assisted living senior housing community setting? Or am I going to have a hybrid model where I do both?

And I don't want to get too much in the weeds. The hybrid model I think is going to come up with some challenges because the model of care ends up being very different for an assisted living or senior housing I-SNP than for a nursing home I-SNP. But the eligibility is determined by the level of care.

And often, to simplify that even further without getting too basic, for most state requirements, that's two activities of daily living that you need help with. So bathing, toileting, transferring, ambulating, feeding, dressing. Those are what we consider the activities, the basic activities of daily living. And if you are deemed and assessed to be deficient in two of them, in most states, that meets a nursing home level of care. But as Amy pointed out, that can happen throughout the year. So, you can be enrolled in an I-SNP whenever you are eligible.

AMY KASZAK: I'm glad you pointed out that the I-SNP model is evolving in many ways, Cheryl. And also, that it is dependent, eligibility is dependent somewhat on state rules. Now that two ADLs in general requirement or eligibility burden for IE-SNPs, when you think about that, most assisted living residents are easily going to meet state level of care requirements.

So, we see a lot of growth right now in IE-SNPs in assisted living and in assisted living and memory care populations and organizations. I think the other interesting thing that we've seen is CMS kind of wrestling with what you just mentioned around the models of care being very different potentially for a long-term nursing home resident versus maybe someone who is still living in their private home or even in an assisted living. And the way that they receive care and services and the supports that make sense for them versus maybe an institutional-based long term care resident.

And in the 2024 proposed rule, Medicare has put out a lot of changes. But one of the interesting ones was further defining and segmenting those I-SNP populations to point out that hybrid which could include residents of long-term care facilities, as well as those who don't live in long term care facilities, versus what CMS is calling FI-SNPs now or the facility-based institutional special needs plans, or the IE-SNPs, which is as it is today the institutional equivalents only. So, I think some evolution going on as CMS is starting to recognize that I-SNPs members can live in multiple settings and that the models of care have to really reflect where they live and how they receive services.

RHONDA DEMENO: I'm hearing state regulation. You see a lot of differences with how the states are regulating these programs?

CHERYL PHILLIPS: For the most part, aside from the nursing home level of care eligibility, remember I-SNPs are Medicare Advantage. They are the Medicare plan that's federally managed.

RHONDA DEMENO: Federally managed. Yeah.

CHERYL PHILLIPS: Now where it gets messy is particularly for long stay nursing home residents. Most of them also have Medicaid. So, they're known as duly eligibles. There are some states that are starting to push back on the idea of I-SNPs, and they would like to have aligned enrollment of everybody who's duly eligible into a D-SNP or a duly eligible SNP.

And we can talk about what are some of the differences, but I can tell you that the SNP Alliance has been very vocal in the advocacy for I-SNPs because when an individual who is duly eligible has Medicare and Medicaid, has been in a nursing home for a year or more, then getting enrolled into a large D-SNP of maybe 50,000 members is not the same as them being enrolled in a very person-centered I-SNP where the team knows them, or they're working closely with the nursing home community, and that they are in a partnership that's very different.

And I'm pro D-SNPs, except when it comes to those that are enrolled in I-SNPs in the nursing home or in the community. The opportunity of having that close partnership of the nurse practitioner, the I-SNP team, the clinicians that work with the I-SNP, and partnering with the providers of care, whether it's assisted living, senior housing, or the nursing home is much more connected, much more interdependent than it is in the relationship with a large D-SNP that acts much more like a managed care plan at a distance.

RHONDA DEMENO: One other question I do have is you had mentioned activities of daily living. And I know from when we're looking at ADLs and how Medicare pays for residents that are residing in a skilled nursing center, would the residents, if they have two or more areas where they need assistance, is there a certain level of assistance? Do they have to be totally dependent, or do they have to require minimal assistance or--?

AMY KASZAK: Yeah. So again, the eligibility is what's determined at the state level. And so, while the two or more ADL rule is kind of a good generic across the board proxy, if you will, for meeting state long term level of care, institutional long-term level of care requirements, it does vary state by state.

So that's where in one state, you actually have to go to the state regs and say, what are the state requirements for institutional level of care? And that's what we go by as the plan for eligibility. Once that eligibility threshold is met, we work like any other Medicare Advantage plan. You can take that from a payment perspective basis. So, the state is really just involved right now for the I-SNPs on that level of care assessment.

CHERYL PHILLIPS: I think implied in that question was also is there a payment difference based on level of dependent need? And no. And I use the two ADLs as just kind of a cognitive shortcut because it is more complicated than that, but that's kind of a general framework. It's more determining the eligibility. Once you're eligible, payment is just like an MA plan, a Medicare Advantage plan. There's not extra money. There is a little bit of an institutional adjustment for those who are duly eligible. There's a little bit of a duly eligible payment adjustment, and there's some changes in some of the quality measures. But for the most part, it's paid just like a Medicare Advantage plan.

RHONDA DEMENO: So, say we have a large CCRC community, and we have some residents in independent living. Because from a claim standpoint from senior living, we are identifying that there are more claims that are occurring in independent living now, and there's also more claims occurring in assisted living than skilled nursing, so because of these resident falls or resident acuity creep.

So, if I'm understanding this conversation correctly, a resident in independent living that may be receiving home care maybe have some declines, they're wishing to stay in their independent living setting, can still qualify for the special needs program.

AMY KASZAK: That is correct, and I call them kind of-- sometimes, they're the hidden I-SNPs members, meaning that they're not the ones that maybe you initially think of. But you describe them very, very well, Rhonda. These are the individuals who have decided that they can stay in independent living. They are paying for the additional care and services that they need to safely keep them in that living level. And I think that's where I-SNPs can actually provide a lot of value because of the tailored services for those higher risk populations.

RHONDA DEMENO: Future episodes, we're going to be talking more about what are those benefits? What's the return on investment for a senior living provider? But before we end this call, I do want to get to some of the specific questions. I think as a senior living operator, I'd really want to as far as like what would a senior living community need to do to partner with an I-SNP?

CHERYL PHILLIPS: I'll start at a high level, and I know that this is Amy's area of expertise because that's what AllyAlign and Curana Health do. But at a high level, it's very difficult for an independent senior living provider to say I hate managed care. I'm going to go B1 because you have to have all of the infrastructure of a Medicare Advantage plan. You have to be able to take full risk. Remember, you are the Medicare Part A and Part B. There's no lifeline to call and say, can you pay for this? There's no carve-outs. You are the Medicare Advantage plan.

Having said that, most providers were look at ways to find collaborative partnerships, and I know that Amy can talk a little bit more about that. Because the advantage is you can spread that risk around. You spread the resources around. Setting up the back side of a health insurance plan is not easy. But once you've done that, you can then start to align with some of the clinical practices, the clinical teams, the resources, putting in palliative care, putting in fall prevention programs.

As a geriatrician, I can speak to just a litany of why these start to be very value added for both the providers and for the recipients of the care. But I'll turn it over to Amy now because it's not just a matter of saying, OK, sign me up. I'll be in I-SNP.

AMY KASZAK: Right. And I'm really glad you started off, Cheryl, with the concept that most senior living organizations really shouldn't become an I-SNP owner. We have some partners who are very successful. But I think the first thing as a senior living operator you should really look at is why? Why are you partnering with a Medicare Advantage special needs plans? What are you looking to get out of it?

For our partners who have said, this is part of our long-term strategy. We have the density. We have the executive and organizational willpower and resources to make it happen, it might be the right thing to start your own plan. But for most senior living organizations, partnering with a collaborative partner like you describe them Cheryl I think is the exact right thing to do. So, to find that collaborative partner, you need to be intentional about what your strategy is. What are you looking for, and what are you looking for first?

So, do you need on-site, reliable, convenient primary care, and is that a reason to maybe partner with a plan who could help bring those resources to you? Do you want more services on site like labs other ancillaries that maybe you just don't have the time to go out and round up the network of people that come on site to provide those services, podiatry, dental, all of those things?

Again, that's something that is a plan with our networks, we can help bring some of those resources almost prepackaged right to you and say, here's some partners who can work here on site and then provide ways to do that. So, what are you looking to get out of this first?

I would also say beyond strategy, you need to really survey your existing resources. What do you have in place today that works from a clinical standpoint? What isn't working for you, that's going to play into your strategy. But it's also going to help you see again what's already in place primary care. For example, is that already a strong partner? That might influence how you think about a SNP strategy or a SNP partnership.

I think right now, thinking about your staffing, what are you able to do with current state of staffing in your building. And being very honest and working with Medicare Advantage partners about what support you're going to need to make the plan successful. And of course, being able to say, what you can contribute to help make the plan successful.

And then don't ever want to overlook the very review of what your residents need. What are the gaps that you are seeing, your medical team, your clinical team? What are you seeing as gaps that potentially could be filled by maybe better supplemental benefits, better coordination of care, more on site services? All of those things that, again, in collaboration, Medicare Advantage SNPs can help bring to your senior living organization.

CHERYL PHILLIPS: Everything Amy said is so correct, but I would also look to see the market in which you serve. Are there other I-SNPs already in place? Would you want to reach out in a collaboration? Are the other partners of that I-SNP the kinds of organizations that you can work with? Is there a lot of MA, Medicare Advantage, in general in your market that may be enrolling all of these folks? And would not it be better to identify the opportunities for an I-SNP that's much more intimate and closely partnered with your provider organization.

So, there's both the internal look. There's the Resident Assessment, which I think is critical. And I so agree with Amy knowing where the gaps are. But I would also then step back and look at your market area and see what's out there because that can give you a lot of clues what to do next.

RHONDA DEMENO: Those are all very good points. And to Amy's point about staffing, we know that's always the elephant in the room. Do these plans require extra staffing? But I think to what Amy had mentioned is that if you have a good solid collaboration of a plan that plan can probably help in that area or bring that expertise.

Because oftentimes, in assisted living, we don't even have a licensed nurse 24/7. So, with these compromised residents that have multiple co-morbidities or ADL needs, what type of program offerings are they putting in place? I'm thinking this would be highly case managed, where that is a definite benefit to the resident and to the community as well. Because if its heavily case managed, and correct me if I'm wrong, are these programs, case managed, the collaboration, does that include oversight and case management? So, do either of you want to talk to that?

CHERYL PHILLIPS: Yeah. I'll jump in because case management is one big piece of it, but it's also clinical support. So, an I-SNP that works whether it's an institutional equivalent in the assisted living setting, and I can give a number of examples across the country, or at a nursing home institutional level of care. What really is the magic sauce is the nurse practitioner or PA, typically a nurse practitioner, who's on site. They're typically there at least once a week, if not more often. They're seeing the residents with changes of condition. They're having conversations with the families. They're working with the primary care docs who might not even be there but every 60 days, and in an assisted living setting, they might not be there at all, and patients are having to go out on their own to see their doctors.

And this clinical team, sometimes a social worker, they often work with pharmacists, they now are a partnership team with what, as you identified Rhonda, is sometimes the minimal staff, particularly after hours. Some I-SNPs of also enrolled in telehealth primary care for after hours and weekends, so that they can work with licensed providers who can help the assisted living staff that we recognize is often not a license like an RN kind of service level.

So, it's not only shared staff. It's not only case management, but it's also a rich and engaged clinical team that provides a lot of direct person service. In fact, I'll just give an anecdotal comment. The biggest marketing tool for I-SNPs is not the pamphlets. It's not flyers. It's the fact that, hey, how come my mom's roommate gets this really nice nurse practitioner that comes and see her every time she doesn't feel well, and my dad doesn't get that? How come? That's the best marketing for an I-SNP.

RHONDA DEMENO: Great point. I know we're sort running low on time, but I'd like to end this with, Amy and Cheryl, do you have any other experiences that you would like to share for a final comment on how the I-SNPs produce favorable resident outcomes?

AMY KASZAK: I'll start with just one that actually came across my desk this morning. So, like Cheryl describes, I-SNPs work so well with senior being partners because we're really able to truly create that care team that CMS wants to see for these high-risk beneficiaries. And we're able to plug in and support clinical needs. We're able to support some of the social needs.

And we do that through a high touch, high intensity, on site, in person preventive care model. And one of the examples that just came across my desk this morning actually leans a little bit more on the social side. So, one of our care team members, we call them a care ally. They have some clinical backing. But they're also really designed, or the position is really designed to support the overall member family and be a connection back to the plan to help identify needs.

And so, we had a member who said that her favorite thing was to read books. And that as her eyesight had been failing, it was harder for her to do that. And our care ally was able to help identify some resources, including some audible type books, where she could continue to enjoy some of her favorites, her classics that she hadn't been able to read out loud in a while because she didn't have a family member who could come in and do that.

And so, it wasn't a medical clinical thing that they were bringing in, but it was something that added to the quality of life. And by working with the senior living organization, we're able to help set up the right technology to make sure that she was able to access that and then working through the plan to help support her.

RHONDA DEMENO: So, it almost sounds like these plans offer a type of primary care.

CHERYL PHILLIPS: We probably need to be clear. They still have their own physician. This is a clinician, and sometimes social worker, sometimes nurse practitioner, sometimes a team of clinicians. They do communicate with the regular doctor of the individual. They don't replace them. But it starts to be this teamwork, and you'll hear that over and over again.

I'll give one very quick example because I was talking to an I-SNP last week or an IE-SNP. This was a woman in assisted living. The family had paid for a sitter, which we know is code for I'm worried that mom's falling down all the time. And mom was falling down several times a day. The community was concerned that they could no longer keep her there, that she would have to go to a nursing home.

The I-SNP enrolled her last week. The clinical team saw her a number of medications that were really the underlying problem, communicated with her physician who wasn't a bad doctor, but he hadn't seen her in three or four months. Was able to get a medical plan together, along with a quick PT evaluation, so they had therapy on site.

The bottom line is they're able to keep this individual where she's living in better care without the falls. Now it's only been a week. So, we see how things go. But that's the example of the partnership. It doesn't replace the primary care doctor. It collaborates. And it also collaborates with the community providers the assisted living, senior living, or nursing home staff.

RHONDA DEMENO: That's an awesome example, and I really appreciate that, and that really hits home because we a lot of times, families do hire sitters to come in and keep an eye on their loved ones because we know that there's limited staff and limited staff requirements based on some state regulations as well. So very good conversation, ladies. I really appreciate your sharing of your knowledge and your expertise in this specific area. Amy, thank you so much for joining us today. I really appreciated the conversation.

AMY KASZAK: You are welcome, and I enjoyed it. Thank you.

RHONDA DEMENO: Cheryl, thank you so much for joining us today. We really appreciated you participating in this very important topic.

CHERYL PHILLIPS: Thank you very much. My pleasure.

RHONDA DEMENO: And for those of you joining our call and would like to get in touch with our panelists, that information will be available on the WTW Podcast page. If you'd like additional information on I-SNP plans, please thrill free to reach out to me at This is the first episode of this three-part I-SNP series. WTW Senior Living Practice prides itself with its mission, which is to help clients provide residents with quality of care, foster a rewarding and engaging atmosphere for employees and residents, and ensure a safe environment for all. This concludes today's podcast. Thanks to all for attending and thank you to our panelists.

SPEAKER: Thank you for joining us for this WTW podcast featuring the latest perspectives on the intersection of people, capital, and risk. For more information, visit the insight section of WTW hopes you found the general information provided in this podcast informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors.

In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast Incorporated in the United States and Willis Canada Incorporated in Canada.

Podcast host

Rhonda DeMeno
Director of Clinical Risk Services, Senior Living, WTW

Rhonda is the host of The Senior Advisor and has over 30 years of extensive senior living experience as a healthcare risk manager, regulatory compliance expert and operations leader.

Podcast guests

Amy Kaszak
EVP of Strategic Initiatives for Curana Health

Amy is a value-based payment veteran with over 25 years of developing innovative payment and care models for high-risk patient populations. In 2013, Amy co-founded AllyAlign Health, the first national company focused on enabling senior living providers to transform the quality of care for residents through Medicare Advantage Special Needs Plans (SNPs).

Cheryl Phillips
President and CEO of the Special Needs Plan Alliance

Cheryl is the President and CEO of a national leadership association for special needs and Medicare-Medicaid plans serving vulnerable adults. Prior to this she was the Senior VP for Public Policy and Health Services at LeadingAge.

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