Institutional Medicare Advantage Plans: The Hidden Medicare Advantage Special Needs Plan Few No About

Nurse Helping an Elderly Patient in a Nursing Home

When most people think about Medicare Advantage, they picture: Standard In-Patient & Out-Patient Care, Doctor visits with Drug, Dental, and Vision benefits. But there’s another, little-known option "Medicare Advantage Special Needs Plan" specifically for those who need more. These are Institutional Medicare Advantage Plans (I-SNPs). These plans aren’t just for nursing home residents—they may also cover people receiving qualifying long-term care "At Home" as well. For families in Upstate South Carolina facing tough decisions about long-term care, understanding I-SNPs can provide clarity, peace of mind, and better care coordination.

Medicare Advantage Special Needs Plan - I-SNP Coverage Explained: What’s Included

Institutional Special Needs Plans deliver everything that Original Medicare covers, plus more. That includes:

• Hospital and skilled nursing facility care (Part A)

• Doctor visits, labs, therapies, and preventive services (Part B)

• Prescription drugs (Part D) built right into the plan

But what makes I-SNPs different is the coordinated care model. Members are assigned a care team—often including nurse practitioners, social workers, and facility staff—who oversee medications, therapies, and ongoing treatments. This team approach reduces hospitalizations and keeps families better informed.

On top of that, many I-SNPs add supplemental benefits like dental, vision, hearing aids, podiatry, transportation, over-the-counter allowances, and even companion or wellness support.

What Does an I-SNP Cover vs Not Cover?

Families often ask: “What does an I-SNP cover vs not cover?” Here’s the truth:

Covered by I-SNPs

• All Original Medicare benefits

• Prescription drug coverage

• Coordinated care through a dedicated team

• Skilled care in nursing homes, assisted living (where approved), or in-home institutional-level care

• Supplemental benefits like dental, vision, hearing, transportation, and wellness

Not Covered by I-SNPs

• Room and board in a nursing home or assisted living (the daily cost of meals, housing, and custodial services are not covered)

• Non-medical home care such as cooking, cleaning, or personal assistance (unless offered as a limited supplemental benefit)

• Out-of-network services (except in true emergencies)

• Unlimited cost-sharing—families still face copays, coinsurance, and deductibles until the plan’s maximum out-of-pocket (MOOP) limit is reached

This distinction is critical: I-SNPs cover medical care, not living expenses.

77% of Seniors Polled Want to Remain at Home for Care

Medicare Advantage Long-Term Care at Home

One of the biggest surprises for families is that I-SNPs don’t only apply to facilities. Some people qualify for institutional-equivalent care at home. If a state-approved assessment shows the individual needs the same level of care as someone in a nursing facility, they can enroll in an Institutional-Equivalent SNP (IE-SNP). This allows families to keep loved ones at home while still receiving the full medical oversight and benefits of an I-SNP.

For caregivers in Upstate South Carolina, this is a game-changer. It means you don’t always have to move someone into a facility to access stronger coverage. A recent AARP survey shows that 77% of all senior citizens polled want to stay at home and receive care.

Medicare I-SNP Out-of-Pocket Costs: What Families Should Expect

Even with broad coverage, families still need to plan for out-of-pocket exposures. Here’s where costs can come in:

1. Daily room and board in a facility – Not covered by Medicare or I-SNPs. This is private-pay, Medicaid, or long-term care insurance territory.

2. Custodial care at home – Non-medical tasks like meal prep and housekeeping are typically out-of-pocket.

3. Copays and coinsurance – These apply for services until the annual MOOP is reached. Once the MOOP is hit, the plan pays 100% of covered services for the rest of the year.

4. Out-of-network care – Using providers outside the I-SNP network can leave you uncovered, except for emergencies.

So while medical coverage is strong and reliable, personal care and living expenses still require planning by the family.

A Day in the Life: How I-SNP Benefits Work When You Qualify

Here’s how it works in practice:

• Step 1: Eligibility – You have Medicare Parts A & B and either live in a qualifying facility or receive a state-confirmed assessment for institutional-level care at home.

• Step 2: Enrollment – You can join an I-SNP year-round once qualified (no need to wait for Annual Enrollment).

• Step 3: Care Team Assigned – You’re paired with a nurse practitioner and care team who coordinate your treatments, medications, and therapies.

• Step 4: Coverage Activated – You get all Original Medicare services, Part D drugs, and supplemental extras through your plan.

This care model reduces ER visits, prevents gaps, and helps families feel more secure.

Why I-SNPs Are Overlooked—and Why That Hurts Families

Large call centers and national ads push mainstream Advantage plans. Institutional plans serve a smaller group, so they don’t get the same visibility. But in reality, they may be the best possible fit for many families in Upstate South Carolina with loved ones in long-term or in-home care. By not knowing about I-SNPs, families often default to less effective plans, missing out on better coordination and reduced out-of-pocket risk.

Frequently Asked Questions About Institutional SNPs

1. Does an I-SNP cover all medical care in a facility or at home? Yes. Medical care is covered, including doctors, therapies, and drugs. But custodial living expenses—like meals and room charges—are not.

2. What are Medicare I-SNP out-of-pocket costs? Families may face copays, coinsurance, and non-covered custodial expenses until the MOOP is met. After that, all covered medical services are 100% paid.

3. Can I use an I-SNP for Medicare Advantage long-term care at home? Yes. With a qualifying assessment, you can stay home and still receive institutional-level care coverage.

4. What does I-SNP cover vs not cover? Covers: hospital, medical, drugs, care coordination, and extras. Does not cover: housing, meals, personal caregiving, or out-of-network care.

5. Do I have to wait for AEP to enroll? No. I-SNPs allow year-round enrollment once you qualify.

Why work with the Shanley Insurance Agency?

At the Shanley Insurance Agency, we’ve been guiding Upstate South Carolina families through Medicare since 1999. With 35+ years of experience, we know the local carriers, the rules, and the pitfalls. Unlike national call centers, we are an independent broker — so we compare multiple carriers to find the right fit for your family. "Best of All, Our Services are Always Free When Helping You Enroll."

Take the Next Step

If your loved one is in a nursing home, assisted living, skilled nursing, or receiving long-term care at home, an I-SNP may be the solution you’ve been searching for. Call the Shanley Insurance Agency today at (864) 868-5194 or visit www.shanleyagency.com. Let us help you protect your family’s health and financial peace of mind—just as we’ve been doing for Upstate SC families since 1999.