Provider-Led I-SNPs Grow 28% in 2021, Outpacing Traditional Medicare Advantage Insurers

Providers of nursing home care and other long-term services continued to expand their Medicare Advantage offerings into the 2021 plan year, as more operators look to gain financial control in a landscape where managed care maintains its steady march toward a Medicare majority.

The number of provider-led Institutional Special Needs Plans (I-SNPs) increased from 76 this year to 98 in 2021, or a gain of 28%, according to a new analysis from consulting firm ATI Advisory. That brings the total representation of nursing homes and assisted living facilities in the Medicare Advantage space to 37%, up from just 9% back in 2015.

“Despite the challenges of managing institutional and high-risk populations during the COVID-19 pandemic, provider organizations continue to see benefits in plan formation for better financial alignment and integration of primary care,” ATI Advisory observed in its analysis.


New players in the space for plan year 2021 include CommuniCare, the Perennial Consortium, and the Los Angeles Jewish Home for the Aging.

I-SNPs, which specifically cover residents of institutional care settings, allow nursing homes to essentially become Medicare Advantage insurers.

In an era when Medicare Advantage enrollment comes closer and closer to representing at least half of all Medicare beneficiaries, launching an I-SNP has become a tempting proposition for post-acute and long-term care operators feeling the squeeze from lower per-day payments from MA plans.


While the startup expenses can be steep, and the risks involved in assuming the full financial cost of care only growing during the pandemic, operators have still taken the plunge: SNN earlier this month profiled a pair of companies that soldiered ahead with new I-SNPs this past year, with the promise of improving care and controlling expenses too strong to avoid.

Amanda Tufano, the CEO of I-SNP partner Genevive, noted that the ability to cover higher levels of in-SNF care under the arrangements can produce better outcomes for residents.

“From a structural standpoint, as we were going through all of the changes that 2020 has brought, it really reiterated the necessity, for the I-SNP patient population and the residents who this is really focused on — our most vulnerable frail elderly — this high need for coordinated care,” she said.

ATI Advisory echoed that sentiment in its analysis.

“The ownership of risk for total cost of health care gives nursing facilities the ability to deploy health care dollars into services that have long been poorly resourced; these services include care management, onsite primary care from NPs [nurse practitioners], and technology,” the company observed. “Savings they generate in reduced hospitalizations and emergency room (ER) visits can then be driven back into the facility care through value-based contracts and gainsharing with the plan.”

ATI acknowledged that I-SNPs face a particularly difficult road ahead as the pandemic shows no signs of slowing. MA plans in general have seen their financial fortunes only increase as younger, healthier seniors delay non-essential services. I-SNPs have had to weather the opposite effects, as COVID-19 laser-targets the elderly residents they’re designed to cover — bringing elevated hospitalizations and health care expenses along with it.

But the increased focus on higher acuity services could beget longer-term benefits.

“The primary care providers enable nursing homes to skill in place, thereby helping to alleviate hospital capacity constraints during local COVID-19 surges,” ATI noted. “For senior living providers — such as the organizations that form the Perennial Consortium — onsite integrated health care services can make a big difference in getting residents the care they need.”

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