By Darian Diepholz (Saint Louis University School of Law class of 2022) & Abbi Coursolle
Jane is 20 years old and living in a multi-family home with her parents, three siblings, and grandparents. She is enrolled in Medicaid and has been visiting a therapist for mental health services for two years. In the past, she has had issues getting to her appointments on time and has had to cancel because she had to pick up extra work shifts or could not find reliable transportation. During the pandemic, she has had the opportunity to complete her appointments via telehealth. Because her family is large and the home small, she does not feel comfortable making video chat appointments with fear a family member will walk in or hear her speaking with her therapist.
Jane lives in a state where the Medicaid program covers her visits when they are completed using text messaging or a live-chat program, allowing her to keep appointments with her provider without any concerns. Jane’s struggle to access the mental health services she needs is not unique among Medicaid enrollees. But only a few states cover text- or chat-based telehealth services, leaving beneficiaries without this crucial tool to access their care. While some states have changed their policies to cover text- and chat-based telehealth during the COVID-19 pandemic, these policies will likely expire when the pandemic ends. California should change its policy to cover text- and chat-based telehealth, both for the duration of the pandemic, and beyond.
Washington’s Text-Based Coverage Through 1135 Waiver
In Washington, Medicaid fee-for-service enrollees are eligible for coverage of telehealth during the pandemic. Previous telehealth policies require telehealth coverage only for synchronous, video-conferencing modalities. However, in March 2020, Washington obtained a 1135 waiver to allow providers to use other platforms aside from video communication to facilitate visits, such as WhatsApp. In July 2021, Washington clarified its guidance on text-based telehealth to include texting as a telehealth modality to “provide assessment, diagnosis, intervention, consultation, supervision and information in lieu of an in-person visit” during the pandemic. However, Washington’s reimbursement guidance to providers cautions against using texting for assessments and treatment, sending a conflicting message.
The state has also issued guidance that requires documentation for telemedicine visits should be the same as in-person, except the documentation must also include the specific modality, verification service was appropriate for telemedicine, locations of client, credentials, consent of care, and any assistive technologies used. Additionally, the guidance confirms that providers should be paid the same rate for delivering services by telehealth as for in-person services. Finally, Washington’s the 1135 waiver also eliminated the requirement that a telehealth provider must have billed the Medicaid enrollee for services within the past three years, allowing telehealth services to be delivered to a new patient. The current waiver will expire once the public health emergency is lifted, and it is not clear whether this telehealth policy will be allowed to continues.
Colorado Live-Chat Coverage Through State Plan Amendment and Senate Bill
Colorado’s Medicaid program also covers expanded telehealth services. In the past, telehealth coverage explicitly excluded text messaging. However, in March 2020, the State announced an emergency rule to expand telemedicine access through live-chat. Colorado notified providers that, during the pandemic, live chat modalities that follow existing policy must be reimbursed at rates comparable to in-person services. Colorado soon after submitted Medicaid State Plan Amendment CO-20-0012 for federal approval, which was granted and made retroactively effective to March 2020, ending prior restrictions on telemedicine in the state plan that required a visual component to services. The new SPA allows telephone and live chat services to be covered.
In June 2020, the state enacted Senate Bill 20-212 to conform with the SPA and emergency rule to allow telephone and live chat to be covered modalities of telemedicine under Colorado law. The law also requires telemedicine to be reimbursed at the equivalent rate as in-person services. A Provider Information Sheet lists authorization codes to be used for billing telemedicine services.
California Should Cover Text-based Telehealth Services in Medi-Cal
California law defines telehealth as a service modality that “facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” Applying this definition, Medi-Cal provides telehealth coverage for live-video or asynchronous services via store-and-forward, which is the “transmission of patient’s medical information” to the provider. The law was amended this year to also allow Medi-Cal coverage of remote patient monitoring, pending federal approval. Current Medi-Cal telehealth policy makes clear that “asynchronous store and forward” via electronic transmission directly to patients, like texts or chats through mobile apps, are not covered. Thus, Medi-Cal will only reimburse providers for its live-video appointments and not text- or chat-based services.
California’s can change its policy to allow for text- or chat-based services, through a State Plan Amendment and making corresponding changes to state law.
As of June 2021, almost 14 million people were enrolled in Medi-Cal. Due to the high cost of living in California, it is likely that many enrollees live with others and would benefit from privacy when obtaining mental health or other sensitive services. Further, recent studies have shown that 1 in 6 California adults experience mental illness, making it particularly important that California take steps now to increase access to services and improve the well-being of all. The state can do this by ensuring that Medi-Cal beneficiaries have access to text- and chat-based services.