Washington, D.C. — A federal advisory body that shapes Medicare policy is pushing for more nursing homes to adopt a specialized insurance model that’s keeping residents out of hospitals — and it’s warning that policy barriers are holding the program back at exactly the wrong time.
The Medicare Payment Advisory Commission (MedPAC) presented new findings this month showing that Institutional Special Needs Plans, known as I-SNPs, are doing what they were designed to do. Residents enrolled in these plans receive more on-site care, fewer hospital trips, and more frequent nurse practitioner visits than those in traditional fee-for-service Medicare.
MedPAC principal analyst Eric Rollins reported that I-SNP enrollees receive about 3.4 nurse practitioner visits per month inside their facility — compared with roughly 2.4 to 2.8 visits for residents in regular Medicare or standard Medicare Advantage plans. That gap reflects a structural shift: I-SNPs are bringing treatment to the resident instead of sending residents out.
A model with promise — and almost no reach
The problem is that almost no one has access to it. By 2024, only about 12% of nursing home residents were enrolled in an I-SNP. Only around a third of facilities even contract with one. Among residents who do have access, enrollment rates sit between 35% and 40%.
Commission Member Tamara Konetzka said I-SNPs may be the closest thing to a real solution for one of long-term care’s most stubborn problems. “We don’t want frail older adults going back and forth to the hospital all the time,” she said, adding that understaffing creates constant pressure to discharge residents to hospitals — and that I-SNP’s model of expanded nurse practitioner presence could break that cycle.
Commission Member Scott Sarran was cautiously optimistic. “We’ve got at least some empirical evidence that I-SNPs are heading us in the right direction,” he said — not enough for a major policy overhaul yet, but directionally positive.
Rules built for someone else
MedPAC’s analysis also flagged structural barriers slowing growth. Medicare Advantage network adequacy rules — written for community-dwelling beneficiaries — require plans to maintain provider counts and meet geographic access standards that don’t fit nursing home residents receiving nearly all their care on-site. CMS has carved out exceptions, but only about 10% of I-SNPs qualify.
The star ratings system creates a separate issue. Most quality measures either exclude frail elderly residents or aren’t clinically appropriate for them, meaning 84% of I-SNP enrollees end up in plans with quality bonuses — not because those plans earned high marks, but because small or new plans automatically receive a 3.5-star floor without being meaningfully measured.
Commission members broadly agreed on removing access barriers. But they were equally clear that growth can’t come without accountability — better quality measures, stronger care model definitions, and improved data on patient experience for this particularly vulnerable population.
Those tensions are familiar to anyone watching managed care’s growing role in nursing homes. Industry reports have documented the mounting frustrations with Medicare Advantage’s impact on post-acute care — and MedPAC’s new analysis adds federal weight to long-standing concerns that the current framework isn’t working for residents who need it most.
