By Sebastian Hickey 

On April 3, Maryland Governor Larry Hogan signed SB 502, requiring the state’s Medicaid program to allow the provision of mental health services using telehealth. The bill also expands the state’s definition of mental health telehealth to include “other telecommunications or electronic technology” like mobile phone apps beyond traditional audio and video telehealth. This expanded definition will allow reimbursement for mental health texting and online chat systems. Maryland’s young people will benefit from increased access to mental health services during the COVID-19 crisis and beyond.

COVID-19 is causing considerable stress, anxiety, and fear. Simultaneously, social isolation has interrupted the provision of most traditional mental health services. State and the federal Medicaid officials have responded by loosening restrictions on telehealth, including for mental health. Health administrators have temporarily relaxed many requirements for live video calling by expanding the eligible sites for video calling and loosening HIPAA regulations to allow good-faith calls between providers and members using video chat. By adding text-based services, Maryland will go a step further, enabling more flexible delivery of mental health services that will reach more Medicaid members.

Unlike many other pandemic-related changes, Maryland’s new definition of mental health telehealth will not expire after the COVID-19 emergency. Instead, it is an important next step in offering the convenience and efficiency of telehealth to more Medicaid members, particularly young people. Using text-based mental health is often more affordable than in-person therapy. While many apps are free, others are inexpensive. Talkspace, which is on the higher end, has a $200 monthly fee for unlimited text, audio, and video chat with a therapist, which is still well below the cost of multiple sessions of therapy.  

Because of the widespread availability of smartphones, texting opens the door to mental health services in areas with too few mental health professionals or poor transportation. Texting can be more convenient, both for members who can’t make the time to get to a therapist and for providers who can serve many more participants via texting than through traditional methods.

The demand for text-based mental health services is growing. In CLASP’s work with young people, we’ve heard support for the use of texting and apps. An evaluation of Nevada’s TextToday crisis line demonstrated that the text-based line was the preferred method of communication among youth. In a 2018 survey of U.S. young people, almost two-thirds reported using a mental health app. Perhaps the greatest indication of text-based mental health’s popularity is the growing number of mental health apps in the marketplace. Headspace focuses on wellness and meditation, the artificial intelligence (AI) chatbot Woebot converses with users about their mood and strategies for self-care, while Talkspace connects users directly with licensed therapists for text conversations. Growing evidence shows that mobile mental health platforms can significantly reduce symptoms of anxiety and depression.

Text-based mental health is changing where and how people get mental health services. And insurers and employers are taking notice. Talkspace is available to members of Premera Blue Cross as well as the employees of dozens of companies and organizations through their Employee Assistance Programs. Woebot is partnering with Blue Cross and Blue Shield of North Carolina to serve University of North Carolina students. Rocky Mountain Health Plans in Colorado works with CirrusMD to provide a therapy chat app to its members. UnitedHealthcare, the nation’s largest insurer, is offering free access to the mental health app Sanvello during the COVID-19 crisis. As text-based mental health services continue to grow, Medicaid programs need to be prepared to take advantage. With more employers and private insurers incorporating text-based mental health into their services, many people with low incomes are being left behind.

Any text-based mental health Medicaid platform would have to address key concerns. Although such services undoubtedly increase access, tens of millions of Americans from low-income communities in rural areas and tribal nations disproportionately lack mobile phones and/or broadband coverage and would be excluded. Text-based platforms must also improve their cultural responsiveness. None of the major platforms have a language option beyond English. There are some commendable examples of  culturally responsive outreach, such as Talkspace’s claim that its therapists are prepared to meet the mental health needs of individuals from the LGBT community. However, cultural responsiveness is neither widespread nor rigorously evaluated. We need research showing how mental health apps perform across racial and ethnic groups.

Text apps have the potential to increase utilization of mental health services by lowering costs and easing access. The technology can also support young people’s mental health needs using a familiar means of interaction. Maryland’s inclusion of texting for mental health telehealth is a pioneering step in Medicaid that other states should follow.