Pharmacy Service Expansion Opportunities

I-SNPs may now be an option for both those who meet the definition of “institutional” and those considered to be “institutional equivalent (IE).” | Viewpoints

by Ashley Gibbons Ellek, Pharm.D. , and Michael Zaleski, Pharm.D. Candidate

Long-term care facilities have historically had close relationships with retail pharmacies, but assisted living facilities (ALFs) will soon be in the spotlight. Changes in the Centers for Medicare & Medicaid Services (CMS) April 2024 final rule are aiming to make it easier for ALFs to participate in specific Medicare Advantage plans and integrate them more closely with other healthcare providers. These new revisions look to remove obstacles for ALFs and allow them to participate in Institutional Special Needs Plans (I-SNPs) beginning Jan. 1, 2025. As a refresher, I-SNPs are a type of Medicare Advantage plan an individual can enroll in if they need an institutionalized level of care, such as that provided in long-term care nursing homes. To be eligible, a patient must require those services for at least 90 days and be enrolled in Medicare Part A and Part B. While I-SNPs cover everything Medicare does, they tailor support toward long-term care needs.

The new CMS rule will group LTC facilities and ALFs together, creating a joint list of institutions eligible for participating in I-SNPs. I-SNPs may now be an option for both those who meet the definition of “institutional” and those considered to be “institutional equivalent (IE).”

Why The Change for ALFs?

ALFs, designed for people who want more independence but need help with daily activities, were previously excluded from I-SNPs since they did not meet the traditional criteria. However, CMS introduced a new, broader definition of “institutionalized,” which may include assisted living facilities. “Institutionalized” is currently defined as a Medicare Advantage-eligible individual who continuously resides in or is expected to reside in one of many long-term care facilities for 90 days or longer.