Hospice providers can collaborate with institutional special needs Medicare Advantage plans (ISNP) to reach patients who reside in long-term care facilities.

ISNPs restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC), skilled nursing facility, a LTC nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.

The nonprofit senior services organization Empath Health, which operates several hospices, recently partnered with the MA organization American Health Plans to bring their services to ISNP-enrolled patients.

“An ISNP is a Medicare Advantage plan for those living in a nursing home. So really, those individuals will get the most out of their care in one place,” Rhonda Sanders-Allamon, chief mission access officer for Empath Health, told Hospice News. “At Empath Health, we’ve been serving patients in the place that they call home for over 48 years. This is the same concept for serving patients in the nursing home setting, which is their home.”

Through the Empath partnership, members of AHP’s American Health Advantage of Florida ISNP will receive interdisciplinary services from TruHealth of Florida, the clinical arm of the ISNP. TruHealth is a newly established joint venture between AHP and Empath.

The U.S. Centers for Medicare & Medicaid Services (CMS) can permit an ISNP that operates either single or multiple facilities to establish a county-based service area, provided that it has at least one long-term care facility that can accept enrollment and is accessible to residents.

The agency then monitors the plan’s marketing and enrollment practices and long-term care facility contracts to confirm that no discrimination occurs.

The payment model aligns with the general Medicare Advantage rubric. The ISNP is a risk-bearing entity that pays the claims and receives revenue from CMS. Typically, this is a fixed-amount, per-member, per-month payment, according to Marybeth O’Connor, vice president of corporate development for American Health Plans. 

The plan does not cover room and board at the facility. That is either handled through private pay or via Medicaid. Many ISNP beneficiaries are dually eligible for Medicare and Medicaid, O’Connor said.

“All Medicare Advantage plans are required to cover all of the same services that original Medicare covers,” O’Connor told Hospice News. “There would be no difference to the beneficiary in terms of covered services. What you get in a Medicare Advantage plan are additional benefits that are not covered by original Medicare.”

ISNP beneficiaries can receive supplemental benefits, including things like routine vision exams and eyewear, hearing exams and transportation to appointments outside the facility. Patients are able to see providers in the community who are able to bill the ISNP.

Being a special needs plan, the ISNP must file a model of care with CMS that details how they will care for their patient population. For contracted nursing homes, the ISNP must supply a nurse practitioner or physician assistant to come to the facility and assist the medical director and clinical team, O’Connor indicated.

When a patient enrolls in hospice, that care is covered through the traditional Medicare benefit. However, the patient can remain enrolled in their ISNP, which will continue to cover supplemental benefits and clinical services delivered by nursing home staff. 

“The hospice care team would then become the primary care team for that member, but we’re still there,” O’Connor said. “We don’t disenroll them, and all our clinicians are still there in the building, helping to care for the other ISNP members. They’re available as well if the hospice team or the facility needs anything.”