Text-based Mental Health in Medicaid: An Advocacy Explainer

What is text-based mental health?

  • Text-based mental health refers to the use of a mobile platform or app that allows a user to chat via text message with a mental health provider.
  • Examples of mental health apps include: Talkspace, Sanvello, and Woebot.
  • Users can message mental health providers (and in some cases artificial intelligence, or AI, chatbots) about how they are feeling, ask questions, and receive guidance about how to address symptoms of anxiety and depression.

Why should Medicaid pay for text-based mental health?

  • Including text-based apps and platforms in Medicaid would increase access to mental health services for people with low incomes:
    • Text-based platforms are less expensive than traditional therapy.
    • The widespread availability of smartphones makes text-based mental health more convenient for people who cannot schedule the time for therapy or who live in areas with too few mental health providers.
    • Texting is the most common form of electronic communication used by young people.

How can text-based mental health become a Medicaid service in my state?

  • Legislative: Change your state’s definition of telemedicine
    • In most states, text messages are excluded from the definition of telehealth.
    • State legislative action is necessary to expand the definition of telehealth to include text messaging and other forms of technology.
    • In April 2020, Maryland expanded its definition of telehealth to include text messaging.
  • Regulatory: Update rules to reimburse for existing mental health services provided using text, phone, or app
    • Medicaid can reimburse for text-based services with billing codes not defined as telehealth.
    • During the COVID-19 pandemic, Medicare has reimbursed for the use of patient portals for “E-visits or patient-initiated online evaluation” using digital medical evaluation CPT codes; states can follow this model in their Medicaid programs. The pandemic has created an opportunity to advocate for the reimbursement of technology used in mental health service delivery.
    • Once the telemedicine definition has been modified to include text messaging, the state Medicaid program can take regulatory action to reimburse for text-based mental health services.
  • Administrative: Make short-term changes permanent
    • During the COVID-19 pandemic, most states have issued emergency guidance expanding Medicaid reimbursement for existing mental health services provided through telehealth. Again, the pandemic has opened a door for administrative changes to Medicaid.
    • A Medicaid State Plan Amendment (SPA) describes a change in the agreement between the state and federal government defining what services are being administered through Medicaid.
      • To make short term changes permanent, submit a State Plan Amendment to the federal Centers for Medicare and Medicaid Services, or CMS
      • If a telehealth service requires a different reimbursement rate than its face-to-face counterpart, the state must submit a SPA.

Apps and other digital tools are opening up mental health services to many people—particularly those with low incomes—who have been overlooked in the past. The upheaval in mental health service delivery caused by the COVID-19 crisis has created an opportunity for advocates to urge changes to their states’ Medicaid systems that would expand the use of text-based telehealth. While mental health issues have been a chronic problem for far too many, the pandemic has shone a light on why it’s important to address mental health needs.