Subdivision 1. Eligibility. (a) An individual who is eligible for mental health treatment services in a psychiatric residential treatment facility must meet all of the following criteria:
(1) before admission, services are determined to be medically necessary according to Code of Federal Regulations, title 42, section 441.152;
(2) is younger than 21 years of age at the time of admission. Services may continue until the individual meets criteria for discharge or reaches 22 years of age, whichever occurs first;
(3) has a mental health diagnosis as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders, as well as clinical evidence of severe aggression, or a finding that the individual is a risk to self or others;
(4) has functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home, or job; an inability to adequately care for one's physical needs; or caregivers, guardians, or family members are unable to safely fulfill the individual's needs;
(5) requires psychiatric residential treatment under the direction of a physician to improve the individual's condition or prevent further regression so that services will no longer be needed;
(6) utilized and exhausted other community-based mental health services, or clinical evidence indicates that such services cannot provide the level of care needed; and
(7) was referred for treatment in a psychiatric residential treatment facility by a mental health professional qualified according to section 245I.04, subdivision 2.
(b) The commissioner shall provide oversight and review the use of referrals for clients admitted to psychiatric residential treatment facilities to ensure that eligibility criteria, clinical services, and treatment planning reflect clinical, state, and federal standards for psychiatric residential treatment facility level of care. The commissioner shall coordinate the production of a statewide list of children and youth who meet the medical necessity criteria for psychiatric residential treatment facility level of care and who are awaiting admission. The commissioner and any recipient of the list shall not use the statewide list to direct admission of children and youth to specific facilities.
Subd. 2. Services. Psychiatric residential treatment facility service providers must offer and have the capacity to provide the following services:
(1) development of the individual plan of care, review of the individual plan of care every 30 days, and discharge planning by required members of the treatment team according to Code of Federal Regulations, title 42, sections 441.155 to 441.156;
(2) any services provided by a psychiatrist or physician for development of an individual plan of care, conducting a review of the individual plan of care every 30 days, and discharge planning by required members of the treatment team according to Code of Federal Regulations, title 42, sections 441.155 to 441.156;
(3) active treatment seven days per week that may include individual, family, or group therapy as determined by the individual care plan;
(4) individual therapy, provided a minimum of twice per week;
(5) family engagement activities, provided a minimum of once per week;
(6) consultation with other professionals, including case managers, primary care professionals, community-based mental health providers, school staff, or other support planners;
(7) coordination of educational services between local and resident school districts and the facility;
(8) 24-hour nursing; and
(9) direct care and supervision, supportive services for daily living and safety, and positive behavior management.
Subd. 2a. Sleeping hours. During normal sleeping hours, a psychiatric residential treatment facility provider must provide at least one staff person for every six residents present within a living unit. A provider must adjust sleeping-hour staffing levels based on the clinical needs of the residents in the facility.
Subd. 3. Per diem rate. (a) The commissioner must establish one per diem rate per provider for psychiatric residential treatment facility services for individuals 21 years of age or younger. The rate for a provider must not exceed the rate charged by that provider for the same service to other payers. Payment must not be made to more than one entity for each individual for services provided under this section on a given day. The commissioner must set rates prospectively for the annual rate period. The commissioner must require providers to submit annual cost reports on a uniform cost reporting form and must use submitted cost reports to inform the rate-setting process. The cost reporting must be done according to federal requirements for Medicare cost reports.
(b) The following are included in the rate:
(1) costs necessary for licensure and accreditation, meeting all staffing standards for participation, meeting all service standards for participation, meeting all requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care, and discharge planning. The direct services costs must be determined using the actual cost of salaries, benefits, payroll taxes, and training of direct services staff and service-related transportation; and
(2) payment for room and board provided by facilities meeting all accreditation and licensing requirements for participation.
(c) A facility may submit a claim for payment outside of the per diem for professional services arranged by and provided at the facility by an appropriately licensed professional who is enrolled as a provider with Minnesota health care programs. Arranged services may be billed by either the facility or the licensed professional. These services must be included in the individual plan of care and are subject to prior authorization.
(d) Medicaid must reimburse for concurrent services as approved by the commissioner to support continuity of care and successful discharge from the facility. "Concurrent services" means services provided by another entity or provider while the individual is admitted to a psychiatric residential treatment facility. Payment for concurrent services may be limited and these services are subject to prior authorization by the state's medical review agent. Concurrent services may include targeted case management, assertive community treatment, clinical care consultation, team consultation, and treatment planning.
(e) Payment rates under this subdivision must not include the costs of providing the following services:
(1) educational services;
(2) acute medical care or specialty services for other medical conditions;
(3) dental services; and
(4) pharmacy drug costs.
(f) For purposes of this section, "actual cost" means costs that are allowable, allocable, reasonable, and consistent with federal reimbursement requirements in Code of Federal Regulations, title 48, chapter 1, part 31, relating to for-profit entities, and the Office of Management and Budget Circular Number A-122, relating to nonprofit entities.
Subd. 4. Leave days. (a) Medical assistance covers therapeutic and hospital leave days, provided the recipient was not discharged from the psychiatric residential treatment facility and is expected to return to the psychiatric residential treatment facility. A reserved bed must be held for a recipient on hospital leave or therapeutic leave.
(b) A therapeutic leave day to home shall be used to prepare for discharge and reintegration and shall be included in the individual plan of care. The state shall reimburse 75 percent of the per diem rate for a reserve bed day while the recipient is on therapeutic leave. A therapeutic leave visit may not exceed three days without prior authorization.
(c) A hospital leave day shall be a day for which a recipient has been admitted to a hospital for medical or acute psychiatric care and is temporarily absent from the psychiatric residential treatment facility. The state shall reimburse 50 percent of the per diem rate for a reserve bed day while the recipient is receiving medical or psychiatric care in a hospital.
1Sp2017 c 6 art 8 s 69; 1Sp2020 c 2 art 2 s 22,23; 2021 c 30 art 17 s 80; 2022 c 98 art 6 s 8
Structure Minnesota Statutes
Chapters 245 - 267 — Public Welfare And Related Activities
Chapter 256B — Medical Assistance For Needy Persons
Section 256B.011 — Policy For Childbirth And Abortion Funding.
Section 256B.02 — Definitions.
Section 256B.021 — Medical Assistance Reform Waiver.
Section 256B.03 — Payments To Vendors.
Section 256B.035 — Managed Care.
Section 256B.037 — Prospective Payment Of Dental Services.
Section 256B.0371 — Performance Benchmarks For Dental Access; Contingent Dental Administrator.
Section 256B.038 — Provider Rate Increases After June 30, 1999.
Section 256B.04 — Duties Of State Agency.
Section 256B.041 — Centralized Disbursement Of Medical Assistance Payments.
Section 256B.042 — Third-party Liability.
Section 256B.043 — Cost-containment Efforts.
Section 256B.05 — Administration By County Agencies.
Section 256B.051 — Housing Stabilization Services.
Section 256B.055 — Eligibility Categories.
Section 256B.056 — Eligibility Requirements For Medical Assistance.
Section 256B.0561 — Periodic Data Matching To Evaluate Continued Eligibility.
Section 256B.057 — Eligibility Requirements For Special Categories.
Section 256B.0571 — Long-term Care Partnership Program.
Section 256B.0575 — Availability Of Income For Institutionalized Persons.
Section 256B.058 — Treatment Of Income Of Institutionalized Spouse.
Section 256B.059 — Treatment Of Assets When A Spouse Is Institutionalized.
Section 256B.0594 — Payment Of Benefits From An Annuity.
Section 256B.0595 — Prohibitions On Transfer; Exceptions.
Section 256B.06 — Eligibility; Migrant Workers; Citizenship.
Section 256B.061 — Eligibility; Retroactive Effect; Restrictions.
Section 256B.0615 — Mental Health Certified Peer Specialist.
Section 256B.0616 — Mental Health Certified Family Peer Specialist.
Section 256B.0621 — Covered Services: Targeted Case Management Services.
Section 256B.0622 — Assertive Community Treatment And Intensive Residential Treatment Services.
Section 256B.0623 — Adult Rehabilitative Mental Health Services Covered.
Section 256B.0624 — Crisis Response Services Covered.
Section 256B.0625 — Covered Services.
Section 256B.0626 — Estimation Of 50th Percentile Of Prevailing Charges.
Section 256B.063 — Cost Sharing.
Section 256B.0631 — Medical Assistance Co-payments.
Section 256B.0635 — Continued Eligibility In Special Circumstances.
Section 256B.0636 — Controlled Substance Prescriptions; Abuse Prevention.
Section 256B.0637 — Presumptive Eligibility; Treatment For Breast Or Cervical Cancer.
Section 256B.0638 — Opioid Prescribing Improvement Program.
Section 256B.064 — Sanctions; Monetary Recovery.
Section 256B.0641 — Recovery Of Overpayments.
Section 256B.0642 — Federal Financial Participation.
Section 256B.0643 — Vendor Request For Contested Case Proceeding.
Section 256B.0644 — Reimbursement Under Other State Health Care Programs.
Section 256B.0646 — Minnesota Restricted Recipient Program; Personal Care Assistance Services.
Section 256B.065 — Social Security Amendments.
Section 256B.0651 — Home Care Services.
Section 256B.0652 — Authorization And Review Of Home Care Services.
Section 256B.0653 — Home Health Agency Services.
Section 256B.0654 — Home Care Nursing.
Section 256B.0658 — Housing Access Grants.
Section 256B.0659 — Personal Care Assistance Program.
Section 256B.0671 — Covered Mental Health Services.
Section 256B.0711 — Quality Self-directed Services Workforce.
Section 256B.072 — Performance Reporting And Quality Improvement System.
Section 256B.073 — Electronic Visit Verification.
Section 256B.075 — Disease Management Programs.
Section 256B.0751 — Health Care Homes.
Section 256B.0753 — Payment Restructuring; Care Coordination Payments.
Section 256B.0754 — Payment Reform.
Section 256B.0755 — Integrated Health Partnership Demonstration Project.
Section 256B.0756 — Hennepin And Ramsey Counties Pilot Program.
Section 256B.0757 — Coordinated Care Through A Health Home.
Section 256B.0758 — Health Care Delivery Pilot Program.
Section 256B.0759 — Substance Use Disorder Demonstration Project.
Section 256B.076 — Case Management Services.
Section 256B.08 — Application.
Section 256B.09 — Investigations.
Section 256B.0911 — Long-term Care Consultation Services.
Section 256B.0913 — Alternative Care Program.
Section 256B.0914 — Conflicts Of Interest Related To Medicaid Expenditures.
Section 256B.0916 — Expansion Of Home And Community-based Services.
Section 256B.0917 — Home And Community-based Services For Older Adults.
Section 256B.0918 — Employee Scholarship Costs.
Section 256B.0919 — Adult Foster Care And Family Adult Day Care.
Section 256B.092 — Services For Persons With Developmental Disabilities.
Section 256B.0921 — Home And Community-based Services Innovation Pool.
Section 256B.0922 — Essential Community Supports.
Section 256B.0924 — Targeted Case Management Services.
Section 256B.0926 — Admission Review Team; Intermediate Care Facilities.
Section 256B.093 — Services For Persons With Traumatic Brain Injuries.
Section 256B.094 — Child Welfare Targeted Case Management Services.
Section 256B.0943 — Children's Therapeutic Services And Supports.
Section 256B.0945 — Services For Children With Severe Emotional Disturbance.
Section 256B.0946 — Children's Intensive Behavioral Health Services.
Section 256B.0947 — Intensive Rehabilitative Mental Health Services.
Section 256B.0948 — Foster Care Rate Limits.
Section 256B.0949 — Early Intensive Developmental And Behavioral Intervention Benefit.
Section 256B.095 — Quality Assurance System Established.
Section 256B.0951 — Quality Assurance Commission.
Section 256B.0952 — County Duties; Quality Assurance Teams.
Section 256B.0953 — Quality Assurance Process.
Section 256B.0954 — Certain Persons Defined As Mandated Reporters.
Section 256B.0955 — Duties Of The Commissioner Of Human Services.
Section 256B.097 — Regional And Systems Improvement For Minnesotans Who Have Disabilities.
Section 256B.12 — Legal Representation.
Section 256B.121 — Treble Damages.
Section 256B.14 — Relative's Responsibility.
Section 256B.15 — Claims Against Estates.
Section 256B.17 — Transfers Of Property.
Section 256B.18 — Methods Of Administration.
Section 256B.19 — Division Of Cost.
Section 256B.194 — Federal Payments.
Section 256B.196 — Intergovernmental Transfers; Hospital And Physician Payments.
Section 256B.197 — Intergovernmental Transfers; Inpatient Hospital Payments.
Section 256B.1973 — Directed Payment Arrangements.
Section 256B.198 — Payments For Non-hospital-based Governmental Health Centers.
Section 256B.199 — Payments Reported By Governmental Entities.
Section 256B.20 — County Appropriations.
Section 256B.21 — Change Of Residence.
Section 256B.22 — Compliance With Social Security Act.
Section 256B.23 — Use Of Federal Funds.
Section 256B.24 — Prohibitions.
Section 256B.25 — Payments To Certified Facilities.
Section 256B.26 — Agreements With Other State Departments.
Section 256B.27 — Medical Assistance; Cost Reports.
Section 256B.30 — Health Care Facility Report.
Section 256B.32 — Facility Fee Payment.
Section 256B.35 — Personal Needs Allowance; Persons In Certain Facilities.
Section 256B.36 — Special Personal Allowance For Certain Individuals.
Section 256B.37 — Private Insurance Policies, Causes Of Action.
Section 256B.39 — Avoidance Of Duplicate Payments.
Section 256B.40 — Subsidy For Abortions Prohibited.
Section 256B.421 — Definitions.
Section 256B.431 — Rate Determination.
Section 256B.434 — Payment Rates And Procedures; Contracts And Agreements.
Section 256B.439 — Long-term Care Quality Profiles.
Section 256B.48 — Conditions For Participation.
Section 256B.49 — Home And Community-based Service Waivers For Persons With Disabilities.
Section 256B.4905 — Home And Community-based Services Policy Statement.
Section 256B.4911 — Consumer-directed Community Supports.
Section 256B.4912 — Home And Community-based Waivers; Providers And Payment.
Section 256B.4914 — Home And Community-based Services Waivers; Rate Setting.
Section 256B.492 — Home And Community-based Settings For People With Disabilities.
Section 256B.493 — Adult Foster Care Planned Closure.
Section 256B.501 — Rates For Community-based Services For Persons With Disabilities.
Section 256B.5011 — Icf/dd Reimbursement System Effective October 1, 2000.
Section 256B.5012 — Icf/dd Payment System Implementation.
Section 256B.5013 — Payment Rate Adjustments.
Section 256B.5014 — Reporting Requirements.
Section 256B.5015 — Pass-through Of Other Services Costs.
Section 256B.51 — Nursing Homes; Cost Of Home Care.
Section 256B.69 — Prepaid Health Plans.
Section 256B.6903 — Ombudsperson For Managed Care.
Section 256B.691 — Risk-based Transportation Payments.
Section 256B.692 — County-based Purchasing.
Section 256B.6925 — Enrollee Information.
Section 256B.6926 — State Monitoring.
Section 256B.6927 — Quality Assessment And Performance.
Section 256B.6928 — Managed Care Rates And Payments.
Section 256B.693 — State-operated Services; Managed Care.
Section 256B.694 — Sole-source Or Single-plan Managed Care Contract.
Section 256B.70 — Demonstration Project Waiver.
Section 256B.71 — Social Health Maintenance Organization Demonstration.
Section 256B.72 — Commissioner's Recovery Of Overpayments.
Section 256B.73 — Demonstration Project For Uninsured Low-income Persons.
Section 256B.74 — Special Payments.
Section 256B.75 — Hospital Outpatient Reimbursement.
Section 256B.756 — Reimbursement Rates For Births.
Section 256B.758 — Reimbursement For Doula Services.
Section 256B.76 — Physician And Dental Reimbursement.
Section 256B.761 — Reimbursement For Mental Health Services.
Section 256B.762 — Reimbursement For Health Care Services.
Section 256B.763 — Critical Access Mental Health Rate Increase.
Section 256B.7635 — Reimbursement For Evidence-based Public Health Nurse Home Visits.
Section 256B.764 — Reimbursement For Family Planning Services.
Section 256B.765 — Provider Rate Increases.
Section 256B.766 — Reimbursement For Basic Care Services.
Section 256B.767 — Medicare Payment Limit.
Section 256B.77 — Coordinated Service Delivery System For Persons With Disabilities.
Section 256B.771 — Complementary And Alternative Medicine Demonstration Project.
Section 256B.78 — Demonstration Project For Family Planning Services.
Section 256B.79 — Integrated Care For High-risk Pregnant Women.
Section 256B.795 — Maternal And Infant Health Report.
Section 256B.81 — Mental Health Provider Appeal Process.
Section 256B.82 — Prepaid Plans And Mental Health Rehabilitative Services.
Section 256B.84 — American Indian Contracting Provisions.
Section 256B.85 — Community First Services And Supports.
Section 256B.851 — Community First Services And Supports; Payment Rates.