What Is ISNP? Medicare Qualifications, Enrollment & More Info
Key Takeaways
- Institutional Special Needs Plans (I-SNPs) are a type of Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). plan you may be able to join if you need the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more.
- ISNPs include Medicare Part D prescription drug coverage, care coordination, and other benefits to help people in a care facillity.
- The costs associated with I-SNPs vary. You may still be required to pay your Medicare Part B premium, plus other costs such as copays, deductibles, and coinsurance.
An Institutional Special Needs Plan (ISNP or I-SNP) is a type of Medicare Advantage plan designed for people who need long-term facility-level care. Like other Medicare Advantage plans, ISNPs are offered by private insurance carriers and have benefits beyond the hospital and medical coverage you get from Original Medicare (Parts A and B).
However, ISNPs are different from most Medicare Advantage plans because they restrict enrollment to eligible individuals and offer coverage that’s specific to facility-level care.
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Medicare Advantage at a Glance
Medicare Advantage plans are offered by private insurance carriers and monitored by the federal government to ensure they meet Medicare standards. Medicare Advantage plans must cover everything that Original Medicare does and may provide other benefits like Medicare Part D prescription drug coverage, vision, dental, hearing, and more. MA plans have rapidly risen in popularity; more than half of Medicare beneficiaries chose a Medicare Advantage plan in 2024.
There are three types of Special Needs Plans (SNP) designed to meet specific healthcare needs. Chronic Condition SNPs are for people with certain chronic illnesses and Dual Eligible SNPs are for people who have both Medicare and Medicaid. Institutional Special Needs Plans are for people expected to spend at least 90 days in a healthcare facility.
Understanding ISNP Medicare Plans
People who live in long-term care facilities or who need a facility level of care while living elsewhere for 90 days or more may be eligible for an Institutional Special Needs Plan (ISNP).
Key Features of Medicare ISNPs
- Include prescription drug coverage (Medicare Part D)
- Provide a Care Coordinator to develop a care plan and coordinate with providers
- All or most care provided in one place – less travel for appointments or hospital care
- May include coverage for physical therapy, personal care, medical equipment, and more
ISNP Eligible Care Criteria
Medicare beneficiaries can be eligible for an ISNP if they live or are expected to live in one of the following facilities for 90 straight days (i.e. not discharged and readmitted within 90 days).
- Nursing home
- Intermediate care facility
- Skilled nursing facility
- Rehabilitation hospital
- Long-term care hospital
- Swing-bed hospital
- Psychiatric hospital
Other facilities may be eligible if they provide a similar level of long-term care. Also, some individuals who live in the community – not in a facility – may be eligible for certain plans if they require the same level of care as is offered in these facilities.
So what counts as an applicable level of care? A medical professional must assess the patient according to state-provided Level of Care (LOC) guidelines. The exact assessment varies by state, but typically includes information about mobility, personal care, eating, memory and decision-making, frequency of physician care, need for therapies (physical, occupational, etc), and medical treatment needed. Eligibility typically requires a situation with moderate to severe impairments or where frequent medical treatment is necessary.
What Does a Medicare ISNP Cover?
All Medicare ISNPs must cover:
- Inpatient hospital stays – at least matching Medicare Part A coverage
- Medical care – at least matching Medicare Part B coverage, including for doctor visits, preventive care, and durable medical equipment
- Prescription drugs – covered medications and costs vary by plan
- Care coordination – a care plan developed specifically for the patient’s needs
- Localized care – limited travel for appointments, testing, therapies, etc.
The additional benefits offered by an ISNP depend on the plan, but they may include:
- Vision
- Hearing
- Dental
- Non-emergency transportation
- Over-the-counter allowance
- Podiatry (foot care)
Costs For Institutional Special Needs Plans
Consider these costs when comparing ISNPs:.
- Premiums: A premium is the monthly amount you pay for insurance. Your cost will vary based on the ISNP you choose, but could be $0. You will continue to pay your Part A and Part B premiums.
- Deductibles: A deductible is the amount you must pay before your insurance will start covering costs. The deductible for an ISNP depends on the plan you choose.
- Copays: A copay is the flat-rate amount you’re responsible to pay for a service.
- Coinsurance: Coinsurance is a percentage of the service cost. In Medicare plans, coinsurance rates are often 0% to 20%.
- Out-of-network fees: Because most ISNPs have a network of providers who’ve agreed on the price of services, using an out-of-network provider typically comes with extra costs.
Out-of-pocket maximum: An out-of-pocket maximum (sometimes abbreviated MOOP) adds up the money you spend in copays and coinsurance for covered services. Once you hit the maximum, your plan covers those costs for the rest of the plan year.
See It In Action
This is how an ISNP might work in reality. These numbers are not from an actual plan; they are an average of the costs from 2025 Institutional Special Needs Plans with an HMO structure.
Primary Doctor Visits | $0 | 20% |
Specialist Visits | $15 | 20% |
Diagnostic Test Ordered | $25 | 20% |
1 Emergency Care Visit | $123 | |
3-day Hospital Stay | $525 | $0 (after $1,676 deductible) |
Note that the above is an example to illustrate the difference in potential care costs. Actual costs differ by plan and service.
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How an ISNP Compares With Other Special Needs Plans
| I-SNP | C-SNP | D-SNP | |
| Name | Institutional Special Needs Plan | Chronic Condition Special Needs Plan | Dual Eligible Special Needs Plan |
| Who It’s For | Those living in a long-term care facility | Those with a qualifying chronic condition | Those eligible for both Medicare and Medicaid |
| Part A | Included | Included | Included |
| Part B | Included | Included | Included |
| Part D | Included | Included | Included |
| Medicaid Coordination | No | No | Yes |
| Condition Care Management | Yes | Yes | No |
How to Choose an ISNP
Depending on where you live and your situation, you may be able to choose from multiple ISNPs. So how do you compare Institutional Special Needs Plans? Investigating these factors might help to make your decision:
Overall cost
The plan premium is often a good place to start looking at health insurance costs, but your complete cost analysis goes much deeper than that. You saw this in the cost breakdown above – deductibles, copays, and out-of-pocket maximums are all part of the full equation. When comparing ISNPs, look at the deductibles, rates for your doctors, and the costs of specific treatments you are likely to need.
Provider network
An otherwise great plan might be all wrong for you if it doesn’t cover your doctors and pharmacy. Many Medicare plans have networks of covered providers and charge more for out-of-network care. Check a plan’s network carefully before choosing. If you can’t find a plan that covers all your providers, you may need to consider switching some.
Prescription drug coverage
Every Medicare Advantage plan with prescription drug coverage as well as every standalone Medicare Part D plan has its own formulary, a list of covered medications. These formularies are organized into tiers with least costly drugs at the bottom and the most expensive on the top, or specialty, tier. Learn how much you’ll pay for the medications that you take regularly on each of the ISNPs you’re considering.
Additional benefits
Many ISNPs go beyond the required benefits to offer coverage for things like vision, dental, hearing, transportation, over-the-counter items, and more. Don’t be overwhelmed by the quantity of benefits offered. Focus on whether the plan offers benefits that are useful for you.
ISNP Enrollment Periods
You can enroll in an ISNP during:
- Initial Enrollment Period (IEP): Generally lasts from three months before your 65th birthday month through three months after your birthday month. You can join Medicare plans during this time.
- Annual Enrollment Period (AEP): Occurs every year from October 15 through December 7. You can join, drop, or switch Medicare plans during this time.
- Special Enrollment Period (SEP): If you move into a qualifying facility, you enter an SEP. This period lasts the entirety of your time in the facility and allows you to change your Medicare coverage.
Because of this enrollment period, you can join an ISNP without waiting for the Annual Enrollment Period. The SEP ends two months after the month you leave the facility.
Putting It All Together
Institutional Special Needs Plans are a type of Medicare Advantage Plan for people who expect to spend 90 days or more in a long-term healthcare facility. These plans cover hospital care, medical services, prescriptions, and care coordination. With an ISNP most care comes to the patient instead of requiring travel, and each may offer a range of additional benefits. A Special Enrollment Period allows enrollment in an ISNP any time while you are a patient at an eligible facility.
Contact a licensed insurance agent to learn about what ISNPs are available in your area and whether there’s one that’s right for you.
Sources
- Institutional Special Needs Plans (I-SNPs). CMS.gov.
- Special Needs Plans (SNP). CMS.gov.
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