Medicaid coverage and benefits are based in a joint state-federal partnership that requires the state to administer Medicaid benefits in accordance with federal laws and regulations. Some have been updated and modernized and others have been in place for many decades, even since the inception of the program. One example is the policy around paying for inpatient and residential care related for individuals with behavioral health disorders. In 1965, Congress passed the Social Security Act which established Medicare and Medicaid. Within this initial bill, Section 1902 (A)(b) created the term Institutes for Mental Disease or IMDs.
An IMD is defined as “a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.”
The federal government established the IMD exclusion which states that no Medicaid payment can be made for services provided either in or outside the facility for patients receiving care in an IMD. One of the goals of this policy was to get people out of institutionalized care, and back into their communities, and increase the availability of publicly funded community based behavioral health services.
States use the State Medicaid Manual, Section 4390 for guidance in determining if a facility is an IMD. Please visit the site above for more specific information regarding IMD criteria.
States have worked to implement IMD policies in such a way that meets the federal guidelines as well as continue to meet the treatment needs of members.
See below for more detailed information related to specific institute types and distinct populations.
| IMD Exclusion | What is an IMD | Examples of potential IMD Settings |
|---|---|---|
| Federal law prohibits states from receiving federal funding for stays within an IMD for adults ages 21-64 and youth in facilities outside the "psych under 21 benefit" | An institution with more than 16 beds primarily engaged in diagnosis, treatment, or care of individuals with behavioral health diagnoses | Crisis Stabilization Units, psychiatric hospitals. residential treatment. nursing facilities |
Behavioral Health Campus Policy
HCPF has published additional guidance for behavioral health campus settings with multiple residential components to navigate Institute of Mental Disease (IMD) criteria. HCPF has worked with providers, subject matter experts, and CMS to design Colorado’s new Behavioral Health Campus Policy. This policy will assist providers looking to expand residential services within their communities.
Please reach out to HCPF_IMD@state.co.us for more information.
Managed Care Authority
The Managed Care 2016 Final Rule from CMS (Centers for Medicare & Medicaid Services) states that individual states utilizing a managed care plan to deliver Medicaid services are able to pay for up to 15 days in a capitation month if services provided fall under the “in lieu of services (ILOS)” authority. Find additional guidance on the use of the ILOS rule.
Colorado’s 1915 (b)3 Waiver has always included the authority to continue receiving FFP for members receiving mental health services at private freestanding psychiatric hospitals as an “in lieu of” service if the member is enrolled with a managed care entity.
Contact John Laukkanen, Behavioral Health Strategy Manager, if you have additional questions.
Inpatient Psychiatric Hospitals
Both private and public facilities in Colorado provide inpatient behavioral health care and meet the criteria of an IMD. Inpatient Psychiatric Hospitals can receive Medicaid reimbursement in line with the In Lieu Of authority described above.
The two state run Mental Health Hospitals (Colorado Mental Health Hospitals in Pueblo & Fort Logan) are IMDs and can only receive Medicaid funding for services provided to members under 21 or over 64 years of age.
Reference the Inpatient and Outpatient Billing Manual for information.
Contact Jessica Short, Hospital Policy Specialist, if you have additional questions.
Child-Serving Residential Facilities
Many children are able to be covered in an IMD setting under the “Psych Under 21” benefit. There is more information about this exemption from the IMD exclusion here.
This benefit allows children under 21 to be placed in a Psychiatric Residential Treatment Facility (PRTF), which can be paid for by Medicaid (including room and board). However, any other facility type (i.e, Qualified Residential Treatment Program) is not eligible under this benefit and needs to adhere to requirements to avoid IMD designation.
For more information regarding PRTFs and QRTPs
- Attestation Form for Facilities Enrolling with Health First Colorado
- Psychiatric Residential Treatment Facility (PRTF)
- September 2019 CMS Guidance re: QRTPs
Contact Christina Winship, Child Health State Plan Policy Specialist, if you have additional questions.
Nursing Facilities & Skilled Nursing Facilities
Since the IMD exclusion applies primarily to members ages 21-64, facilities that serve members 65 years and older navigate the IMD policy by ensuring they keep their census of members with a behavioral health diagnosis under 50%.
All Nursing Facilities are required to screen admissions for serious mental illness to ensure members have the appropriate care and services.
Please reference the Pre-Admission Screening and Resident Review Program webpage for more information.
More information on Nursing Facilities and what services are available through Medicaid can be found on the Nursing Facilities website.
Please note that Assisted Living Facilities are considered Home and Community-Based Services and do not assess for or treat serious mental illness.
Substance Use Disorder (SUD) Providers
Under Colorado’s 1115 Waiver, residential SUD Facilities with more than 16 beds are eligible to receive reimbursement through Health First Colorado (Colorado’s Medicaid program).
For more information, visit the SUD webpage.
Contact our SUD policy staff at HCPF_sudbenefits@state.co.us if you have additional questions.
Recent IMD-Related Projects
ARPA 2.03 IMD Risk Mitigation Project
HCPF has explored the parameters of a Mental Health 1115 Waiver related to the federal IMD exclusion guidelines in order to seek flexibility for a continuum of mental health services on a campus for residential and step-down mental health services. This project considered barriers to supporting continuum or step-down services such as shared staffing and number of treatment beds on a campus, as well as the 15-day reimbursement policy.
More details can be found on the ARPA 2.03 IMD Risk Mitigation Project Fact Sheet.
SMI/SED 1115 Demonstration Waiver Amendment Work
As a result of the APRA 2.03 project, the State of Colorado is pursuing an amendment to its current 1115 SUD Demonstration Waiver to increase coverage for members needing care in an inpatient psychiatric setting. Documents that were submitted by HCPF for this 1115 SUD Demonstration amendment can be found 1115 Sud Waiver webpage.
Resources
- IMD Member Retro Enrollment Fact Sheet - revised 9/26/2023
- Payment Policy for Member Stays in Institutes of Mental Diseases (IMD) - March 2023 - A summary of statutory authority that guides current HCPF payment policies for member stays in IMDs.
- State Medicaid Manual, Section 4390 - Federal guidance that outlines criteria states should use to determine IMD status
- 2016 Final Rule from CMS - 2016 report from CMS granting states the authority to provide Medicaid coverage for inpatient psychiatric up to 15 days length of stay.
- 2020 Final Rule from CMS (Section IV) - Overview of CMS Final Rule documentation updating regulatory framework of managed care.
- Related Fact Sheet - Medicaid & Children’s Health Insurance Program (CHIP) Managed Care Final Rule, 2020
- 2023 CMS Guidance re: In Lieu of Services (ILOS)