CMS Pub. 100-16, ch. mc86c16b, § 40.2.3

Institutional Equivalent SNPs

(Rev. 123, Issued: 08-19-16, Effective: 08-19-16, Implementation: 08-19-16)

When an individual elects to enroll in an I-SNP before she/he has received at least 90 days of

institutional LOC, the I-SNP may use a number of sources of information to show that the

individual’s condition makes it likely that either the length of stay or the need for an institutional

LOC will be at least 90 days. Examples of sources of information that CMS considers appropriate for

this purpose include: a state LOC assessment tool; current Minimum Data Set (MDS) data; or a letter

from the nursing facility on the organization’s letterhead stating that the nursing facility expects the

enrollee to require a stay in excess of 90 days.

Pursuant to section 1859(f)(2) of the Act, individuals living in the community may enroll in an I-SNP

only if they have been determined to need an institutional LOC. CMS permits I-SNPs serving

individuals living in the community who require an institutional LOC to restrict enrollment to those

individuals that reside in, or agree to reside in, a contracted assisted living facility (ALF) or

continuing care community, as this may be necessary to ensure uniform delivery of specialized care.

Use of an ALF or continuing care community is optional. If a community-based I-SNP limits

enrollment to individuals who reside in a specific ALF or continuing care community, a potential

enrollee must agree to reside in the MAO’s contracted ALF or continuing care community in order to

enroll in the SNP. The SNP must demonstrate the need for the limitation on enrollment, and must

describe how community resources will be organized and provided.

MAOs requesting to offer a new, or expand an existing, I-SNP to individuals living in the community

and requiring an institutional LOC must submit to CMS information via HPMS that pertains to:

• The state LOC assessment tool; and

• The entity performing the LOC assessments.

An entity unrelated to the MAO must perform the assessments. This independent entity may not be

an employee of the MAO or its parent organization, and must be an independent contractor or

grantee. In addition, the independent entity may not receive any kind of bonus or differential

payment for qualifying members for the SNP.

MAOs must submit this required information as a part of their SNP application. Applications for this

type of I-SNP are reviewed on a case-by-case basis for approval during the annual MA application

cycle. Refer to section 30 of this chapter for further information regarding the SNP application

submission.