A special needs plan is a Medicare Advantage plan that is specifically designed to provide focused care coordination to a specialized population. In an Institutional Special Needs Plan (ISNP), the target population is institutionalized. In this context, institutional means the members reside in a long-term care setting with no immediate plans for discharge. An ISNP, in effect, replaces traditional Medicare and is an all-in-one plan that usually covers inpatient services, outpatient services, and (under a tag-on Part D service) prescription drugs. Eligibility requirements include residing in a long-term care facility with no anticipated discharge, being currently enrolled in Medicare Part A/B, and living in a particular parish/county in which the plan is licensed. Each Special Needs Plan is required by CMS to have a Model of Care (MOC). A MOC is a lengthy and comprehensive document that lays out how an ISNP will take care of the institutionalized members.
Nurse Practitioners are at the forefront of providing preventive and proactive care in an ISNP. Many ISNP plans also have Registered Nurse Case Managers (RNCMs) who coordinate care for the members. Each member is assessed and stratified into a “Risk for Hospitalization” level. This risk level determines their individualized care plan and proactive rounding schedule. This results in personal, face to face visits with members as often as weekly or even more frequently for some high-risk members. In an ISNP, provider encounters are not subjected to the same medical necessity requirements as traditional Medicare. This means the NP can see the patient more frequently to prevent issues and declines.
With practitioners rounding frequently, a higher level of care can be provided to members in the comfort of their residence (the nursing facility). The goal is to treat the members proactively in place and prevent unnecessary hospitalizations, ED visits, and readmissions. Hospitalizations in the long-term care population can result in confusion, debility, and a higher risk of infection, and are uncomfortable and often scary for members and their families.
Provider Health Services (PHS) is involved in multiple ISNPs. We recruit, train, and manage the Plan NPs and RN Case Managers. We also provide back office support, such as coding and billing. Having trained, professional coders is an asset to any ISNP based on the unique payment model. PHS can also help plans develop their unique ISNP Models of Care.