LTC-Led I-SNPs Continue to Launch for Now — But 2022 Will Be Year to Watch

When conferences were a staple of business development and not potential sources of contagion from COVID-19, skilled nursing providers would frequently pack the rooms featuring sessions on institutional special needs plans (I-SNPs).

Under this model, SNFs can move into the Medicare Advantage world by offering their own insurance plans to beneficiaries who are living in a facility or need in-home nursing care.

For many SNFs, I-SNPs were seen as a way to escape the financial pressures of dealing with a range of payers, including managed care plans and accountable care organizations. And during the COVID-19 pandemic, having a stake in the plans, with their integration of care on-site, has proven both financially and clinically helpful.


SNFs have been enthusiastic about the plans, in short, even though other options for value-based care exist and warnings abound about how the model may not be right for every provider. In some ways, that makes it unsurprising that I-SNPs led by long-term care (LTC) providers grew by 28% for plan year 2021, according to an analysis from the consulting firm ATI Advisory.

Specifically, LTC-backed I-SNPs went from 76 plans in plan year 2020 to 98 in 2021, and went from 9% of the total I-SNP offerings in 2015 to 37% in 2021.

“This means that in the I-SNP market, growth of LTC provider-led I-SNPs is outpacing growth in insurer-led I-SNPs,” the analysis noted.

Source: ATI Advisory

The newer organizations entering the market were not a surprise to Anne Tumlinson, CEO of ATI Advisory, but she had expected something of a drop-off from organizations that had a longer track record in the I-SNP space.

“I thought some of the older, more established organizations that have multiple plans … would see a big drop-off,” she told SNN in a November 17 interview. “I thought we would just see some of those plans folding and not being reissued next year, and that just largely isn’t the case.”

She had expected some kind of decline for many of the reasons I-SNPs tend to come with caution labels for SNFs: The model is challenging, particularly in caring for a frail and vulnerable population, with lower enrollment numbers and easier ways to lose enrollment.

But on the other hand, during the pandemic, they have some upsides too.

“Most of these plans are working with clinical models that are a lot stronger than what you would normally see in a nursing home or an assisted living facility,” Tumlinson pointed out. “They have the ability to pay for telehealth and the ability to get a nurse practitioner at the first sign of distress and be right there. … If anything has taught us that we need really strong clinical models on-site in these facilities, this situation is that.”

She was particularly surprised by the slowed rate of growth for non-provider-led I-SNPs, especially compared to the rate of growth for provider-led plans. The former grew by 10 from 2020 to 2021; the latter increased by 14 plans in the same time.

“The providers are all in. They’re committed, is sort of my takeaway from all this,” Tumlinson told SNN.

At least, that is the takeaway for the current set of data. But Tumlinson acknowledged that in many cases, plans launching in 2021 would have gotten the process started well before the pandemic — making 2022 the year to watch. Launching an I-SNP can take anywhere from several months to more than a year, and even then, generating stability can take some time, as one major I-SNP administrative partner pointed out in a 2019 interview.

“We like for our plans’ Year 1 to be stability. That means that the plan is breaking even for the full year — which most MA plans would kill for, by the way,” AllyAlign president and CEO Will Saunders told SNN at the time. “Then we want Year 2 to be what we call viability, which is you’re beginning to generate returns. Then Year 3 is what we call optimization, where you’ve really learned the levers of success, your facility understands it, and you are really driving superior outcomes for your members and their families.”

The pandemic is likely to do away with or heavily scramble those timelines, as other plans launching I-SNPs noted to SNN earlier this year. But it doesn’t necessarily mean that the model is doomed in the SNF world; it may end up being put on pause on some level instead.

That said, Tumlinson does believe 2022 will be an even more critical year to examine from the perspective of I-SNP offerings. In terms of metrics to watch to assess I-SNP health, outsiders can track the number of plans, enrollment, premium charges, out-of-pocket costs and supplemental benefits, but enrollment is the main metric to watch, Tumlinson said.

January and February 2021 will likely provide the most insights when the Centers for Medicare & Medicaid Services (CMS) puts out its enrollment file for I-SNPs, she explained. Anyone working within one of the plans would be watching hospitalization rates and COVID-19 infections among the enrolled population.

But when it comes to assessing the impact of COVID-19 on interest in I-SNPs by long-term care providers, the year after next will be key, Tumlinson said.

“I will definitely be holding my breath for 2022 … and yet I also remain optimistic,” she told SNN. “A couple trends that I’m noticing: One is we might not see new organizations coming into 2022, but I think we would still see the existing organizations offering more plans. These are counts of plans, not the organizations that own the plans. Some of the organizations that have already been in the space actually increased the number of plans that they were offering from 2020 to 2021, despite all the headwinds.”

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