The Department of Human Services (DHS) has received confirmation from the Centers for Medicare & Medicaid Services (CMS) regarding the applicability of the federal Medicaid inmate exclusion to Intensive Residential Treatment Services (IRTS) facilities with a locked physical plant. It also outlines IRTS eligibility, statutory and operational requirements for locked and unlocked settings and considerations related to court-ordered treatment, competency attainment, client rights and Medicaid billing.

CMS Determination: Applicability of the Medicaid Inmate Exclusion

CMS affirmed the DHS position that IRTS programs with a locked physical plant are not public institutions. Accordingly, care provided in these settings is not subject to the federal Medicaid inmate exclusion. This determination is based on the nature and operation of IRTS programs, including their independence from the justice system and their status as community-based behavioral health treatment providers.

Key considerations include:

• Community-based treatment: IRTS providers operate independently of the justice system and are not the responsibility of, or under the administrative control of, a governmental unit.
• Clinical admission criteria: Admission is based on medical necessity and clinical eligibility rather than solely on legal status or court order.
• Client rights: Individuals retain the right to leave the facility subject to applicable civil commitment laws and other lawful restrictions.
• Facility operations: A locked physical plant does not, by itself, make an IRTS program a secure facility. IRTS programs do not maintain a chain of custody and cannot detain clients or use restraints.

IRTS Overview

Intensive Residential Treatment Services (IRTS) are community-based, medically monitored mental health services intended for adults who require intensive treatment and support beyond what can be provided in less restrictive community settings. IRTS generally has a 90-day placement expectation. Continued services beyond 90 days require authorization and must be medically necessary.

Individuals may receive IRTS in locked or unlocked program settings, depending on their clinical needs, safety considerations, functional support requirements and available community services.

The level of care remains the same regardless of whether treatment occurs in a locked or unlocked setting. However, an individual's level of need may require additional treatment and safety considerations when determining the appropriate program structure.

IRTS Eligibility Requirements

Locked and unlocked IRTS programs share the same core eligibility and level-of-care requirements.

A court order does not independently establish IRTS eligibility or require a program to admit an individual.

Locked IRTS

Under Minnesota Statutes, section 245I.23, subdivision 19a, locked IRTS programs are subject to specific requirements governing facility operations, client rights and safety.

These requirements include:

• Exit doors are staff-controlled and locked, requiring staff assistance to allow clients to exit.
• Staff may assess safety, redirect clients and initiate crisis procedures when a client attempts to leave.
• Programs must maintain documentation of applicable court orders when a client is present under a court-authorized restriction on leaving.
• At admission, clients must be informed of their rights under Minnesota's patient rights law, including the right to leave and the potential legal consequences of leaving against medical advice.
• Clients must also be informed that their ability to leave may be restricted under civil commitment proceedings pursuant to Minnesota Statutes, chapter 253B.
• Any civil commitment-based restrictions on movement must be reflected in the treatment plan.

Although exit doors may be locked and staff may manage access to the exits, locked IRTS programs are not secure facilities. They do not have authority to detain clients or maintain a chain of custody.

Unlocked IRTS

In unlocked IRTS settings, doors may be locked from the outside, but staff do not control clients' ability to exit in the same manner as in a locked program. Clients may sign in and out and may leave without staff intervention.

Requirements Applicable to Both Settings

In both locked and unlocked IRTS programs:

• Clients may leave against medical advice, subject to applicable legal restrictions.
• Staff must assess safety risks when a client attempts to leave or leaves the program.
• Programs must respect applicable client rights and follow required safety and crisis procedures.
• Restraints are prohibited in IRTS programs, whether locked or unlocked.

Court-Ordered Treatment and Competency Attainment

Court involvement does not change the fundamental purpose, eligibility requirements or operational limitations of IRTS. Accordingly:

• Courts may order treatment in a locked IRTS setting, but the individual must meet the program's eligibility criteria.
• A court cannot require a facility to accept an individual.
• Admission remains subject to clinical appropriateness and the program's consent.
• IRTS programs do not maintain a chain of custody and cannot function as secure detention facilities.
• Competency attainment is not a Medicaid-billable IRTS treatment service. IRTS programs may provide documentation to support the competency attainment process but may not deliver competency attainment services as part of the IRTS benefit.
• An IRTS is not part of a chain of custody consideration.
• A related statutory consideration is the 48-hour rule.

Client Rights and Medicaid Payment Requirements

All IRTS programs must ensure that clients understand their rights.

The presence of locked doors does not eliminate client rights or independently establish authority to restrict an individual's movement. Any restrictions must be supported by applicable law and documented as required. Clients must be informed of their right to leave the facility and advised that leaving against medical advice may have legal consequences. Admission procedures must also explain any applicable civil commitment restrictions.  

Medicaid payment remains subject to applicable eligibility, medical necessity, authorization and billing requirements. The CMS determination regarding the inmate exclusion does not make competency attainment billable under the IRTS benefit or eliminate other Medicaid coverage requirements.

For questions about this announcement or the applicability of these requirements, please contact the DHS IRTS Policy Lead at dhs.adultmhact_irts@state.mn.us.