D.C. Medicaid Funds Mental Health Coaching by Text that Centers Racial Justice

Innovations in Youth Mental Health

By Nia West-Bey

In 2022, we have seen growing attention on the youth mental health crisis in this country. The U.S. Surgeon General’s office issued an unprecedented advisory about the critical state of youth mental health. In response, and the Biden Administration released a comprehensive plan and budget proposal. Young people were facing growing mental health need well before the COVID-19 pandemic, particularly young people of color and those living in poverty. The pandemic has exacerbated and amplified these existing inequities. Although the scope of the challenge is great, communities have launched innovative approaches in youth mental health that meet the moment and have the potential to transform access to care.

In our Policy Advancing Transformation and Healing (PATH) technical assistance work, we heard even before the pandemic about young people’s desire to receive regular check-ins from a caring adult and to be able to access support on demand through their phones. Sometimes referred to as “mHealth” or digital therapeutics, these interventions deliver evidence-based therapeutic interventions that are driven by high-quality software programs to prevent, manage, or treat a medical disorder or disease. These services often include a combination of artificial intelligence (AI) and live mental health providers to provide ongoing care and monitoring. Young people appreciate the additional flexibilities in telehealth during the pandemic that have allowed greater access to care via phone and video. However, text and app-based supports don’t typically fit well into existing telehealth models and are generally not reimbursable through Medicaid.

In January 2022, the District of Columbia announced a new, Medicaid funded text-based mental health support to young people. The service is delivered through a partnership between MindRight Health and one of D.C.’s Medicaid managed care organizations (MCO); it provides free mental health coaching by text, with a priority for young people ages 13 to 25. The service is free for people whose Medicaid benefits are provided through the partner MCO.

MindRight Health was founded in June 2019 with the mission of making mental health support radically accessible and inclusive. Issues such as dismantling white supremacy, radical self-love, and bringing people from historically marginalized communities to the decision-making table define how they operate. MindRight promises culturally responsive, judgement-free, daily coaching over text message. The organization is founded by a woman of color, and the majority of staff and coaches are also people of color.

The partnership between MindRight and D.C. Medicaid managed care is designed to learn how to leverage Medicaid to bring this type of racial justice focused mental health care to communities and young people who are not served well by existing systems. MindRight is currently in conversations with the other MCOs in D.C. to expand access to additional young people. The company is also speaking with several other states about how to advance a similar model.

Policymakers and advocates around the country have expressed interest in growing equitable access to mental health care for youth through text. Several key policy pre-conditions make this model work:

  • Managed care structure: Text-based mental health support currently is not directly billable to Medicaid. Managed care organizations can act as an intermediary, enabling the use of Medicaid dollars to fund text services that don’t fit neatly into traditional telehealth models.
  • Capitated payment: Text-based therapies don’t fit well into a fee-for-service (FFS) billing structure. Text exchanges can’t easily be quantified in the typical 15-minute billing increments required for FFS payment. Capitated payments are an alternative in which MCOs are reimbursed through a per-member, per-month structure. The MCO is then free to fund whatever services will best support members within that capitated rate.
  • “Carved-in” behavioral health: In most places, behavioral health services are “carved out” from other health services, sometimes managed by a different MCO or through a different plan. A “carved-in” structure ensures that text-based services are available to a broad group of young people through their standard health plan. This approach recognizes that mental health is health and facilitates more effective connections between physical and mental health services.

This Mental Health Awareness Month, we are highlighting transformative solutions aligned with our mental health policy framework. D.C.’s text coaching program demonstrates that innovative solutions are possible at the intersection of Medicaid, technology, and racial justice.