chevron-down Created with Sketch Beta.
    June 01, 2021

    Is the Future of Behavioral Health Digital?

    By Nina Zhang, Esq., Arcarius Law, Los Angeles, CA

    Introduction

    According to the National Survey on Drug Use and Health, in 2019, only 45 percent of adults with any mental illness received mental health services.1 There are many reasons for this gap in care, one of them likely being the difficulty of finding a therapist. There are 5,807 mental healthcare professional shortage areas in the United States. 2  Can telehealth help fill this gap? 

    In 2020, businesses in the “digital behavioral health” space raised $2.4 billion in venture-capital funding, compared to $539 million in 2019.3  In October 2020, Teladoc, a multinational telemedicine and virtual healthcare company, launched a tele-mental health service.4  In January 2021, Talkspace, a mobile text, audio, and face-to-face therapy app, announced plans to go public in a $1.4 billion SPAC deal.5 Talkspace seems to help solve the challenge of finding a therapist by offering individuals the choice of at least three therapists when they sign up for its service. A number of health plans offer Talkspace to their beneficiaries, including Cigna,  Humana, Optum, and Premera Blue Cross Blue Shield.6

    Based on a policy report on telehealth released by the National Committee on Quality Assurance (NCQA), a private accreditation organization for health plans, behavioral health utilization via telehealth during the pandemic increased.7 There are likely many reasons for this growth. Psychological distress and loneliness have been higher during the COVID-19 pandemic.8 In addition, the availability of tele-mental health services likely has reduced no-show rates. For example, the baseline no-show rate for psychiatry services is between 19 percent and 22 percent of appointments, while MDLive, a telehealth company that enables patients to consult with a variety of doctors 24/7 from their mobile phones, reports no-show rates of only 4.4 percent – 7.26 percent for its behavioral health telehealth visits.9 With telehealth, patients can talk to a therapist in the privacy of their own homes. Telehealth can also reduce transportation time and eliminate other barriers, such as the need to take time off from work and finding childcare.

    What is Digital Behavioral Health?

    Behavioral health is a broad term that examines how a person’s daily actions can affect their mental state, while mental illness is often associated with a diagnosis.10  Digital behavioral health is a broad term for the prevention, diagnosis, treatment, and/or management of behavioral health conditions, including mental illnesses, using digital technology. The technologies can serve numerous functions: (1) support clinical diagnosis and/or decision making; (2) improve clinical outcomes through behavior change and enhancement of patient adherence and compliance with treatment; (3) perform as standalone digital therapeutics; and (4) deliver disease-related education. Digital behavioral health includes teletherapy, coaching, self-help/guided programs, and wearables.

    Coverage and Reimbursement of Behavioral Health Services: A Brief History

    Broad coverage of mental health services in the United States only began less than 30 years ago, with the passage of the federal Mental Health Parity Act (MHPA).11 The law requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a large group health plan, i.e., those for employers with 50 or more employees. In 2008, the Paul Wellstone and Pete Domenici Mental Health Party and Additional Equity Act (MHPAEA) expanded parity requirements for these plans.12 Under MHPAEA, financial requirements for benefits, including copayments, deductibles, out-of-pocket maximums, and limitations on treatment benefits (such as caps on visits with a provider or days in a hospital visit) for mental health or substance use disorders cannot be more restrictive than the insurer's requirements and restrictions for medical and surgical benefits.13

    Neither MHPA nor MHPAEA require coverage of mental health, however.  The Patient Protection and Affordable Care Act (PPACA) of 2010 changed that; it requires that mental health and substance use disorder services be one of 10 essential health benefit categories in non-grandfathered, individual, and small group plans, a.k.a. qualified health plans.14 PPACA also requires rehabilitative and inpatient services to support people facing behavioral health challenges.15 It is up to the states, however, to decide the specific mental health and substance use disorder services they want to offer.16 Additionally, PPACA mandates parity in mental health services for qualified health plans.17

    Medicare and Medicaid each have their own rules. PPACA does require Medicaid alternative benefit plans (ABPs) to cover the 10 essential health benefits.18 An alternative to traditional Medicaid benefits, ABPs offer benchmark and benchmark-equivalent benefit packages for specific groups.  In 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that applies MHPAEA to Medicaid managed care organizations (MCOs), Medicaid ABPs, and the Children’s Health Insurance Program.19

    Digital Behavioral Health: Pre-Pandemic

    Pre-pandemic, various parts of the healthcare system showed signs of adopting digital behavioral health.

    Commercial Health Plans

    Commercial health plans can set their own rules, a.k.a. policies, about telehealth coverage.

    In 2017, NCQA introduced telehealth for seven behavioral health measures: (1) antidepressant medication management; (2) follow-up care for children prescribed ADHD medication; (3) follow-up after hospitalization for mental illness; (4) follow-up after emergency department visit for mental illness; (5) follow-up after emergency department visit for alcohol and other drug abuse or dependence; (6) initiation and engagement of alcohol and other drug abuse or dependence treatment; and (7) use of first-line psychosocial care for children and adolescents on antipsychotics.20 The changes apply to the measurement of healthcare quality.21

    Traditional Medicare

    On the government payor side, Medicare has covered a range of behavioral health services delivered via telehealth. As defined, “telehealth” services are services delivered by an interactive telecommunication system: audio and video equipment permitting two-way real time interactive communication between the patient and the distant site clinician.22 They are:

    • office or outpatient visits;
    • individual and group health and behavior assessment and intervention;
    • individual psychotherapy;
    • psychiatric diagnostic interview examination;
    • pharmacologic management; neurobehavioral status examination;
    • alcohol and/or substance abuse assessment and intervention;
    • face-to-face behavioral counseling for alcohol misuse;
    • annual depression screening;
    • behavioral counseling to prevent sexually transmitted infection;
    • annual, face-to-face behavioral therapy for cardiovascular disease;
    • psychoanalysis;
    • family psychotherapy;
    • critical care consultations;
    • comprehensive assessment of and care planning for patients requiring chronic care management;
    • psychotherapy for crisis.

    Restrictions, however, have always been in place for telehealth in traditional Medicare (i.e., Medicare Part A and Part B). One key restriction is the originating site requirement. An originating site is the location where a Medicare beneficiary receives services. The beneficiary must receive treatment outside a metropolitan statistical area or in a rural health professional shortage area.23 Additionally, the service must take place at a physician’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, renal dialysis center, skilled nursing facility, or community mental health center.24 Beginning July 1, 2019, however, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removes the originating site geographic condition and adds an individual’s home as a permissible originating telehealth services site for treatment of a substance use disorder or a co-occurring mental health disorder.25

    While restrictions have always been in place for Medicare telehealth (as defined above), Medicare beneficiaries can receive behavioral health services through services that CMS does not consider telehealth: e-visits; virtual check-ins; behavioral health integration; transitional care management; chronic care management; and remote patient monitoring. For example, chronic care management provides for non-face-to-face consultations. Behavioral health conditions such as depression are considered chronic conditions.

    Medicare Advantage

    Medicare Advantage is another story. With the passage of the CHRONIC Care Act in 2018, Medicare Advantage plans can build telehealth services into their “base” premium bids rather than offer it as a mere supplemental benefit.26

    Medicaid

    Each state has its own Medicaid program, with its own rules about telehealth. For instance, in Pennsylvania, telehealth (defined as the delivery of compensable behavioral health services at a distance using real-time, two-way interactive audio-video transmission) cannot be utilized to deliver services to individuals in their homes, unless services are being delivered as part of Assertive Community Treatment, Dual Diagnosis Treatment Team, or Mobile Mental Health Treatment services. Additionally, staff must be trained in the use of the telehealth equipment and protocols to provide operating support. Further, staff trained to provide in-person clinical intervention must be present.27

    Fraud, Waste, and Abuse Enforcement

    The government has enforced fraud, waste, and abuse violations in this area pre-pandemic. For instance, in July 2016, psychiatrist Dr. Anton Fry allegedly submitted improper claims to Medicare for psychiatric services provided over the telephone to certain Medicare beneficiaries instead of by meeting with them in the office and treating them in person.28 The patients were not located in rural health professional shortage areas, and Dr. Fry did not use interactive audio and video communications.29 Dr. Fry agreed to pay $36,000 to settle False Claims Act allegations.30

    Digital Behavioral Health: Pandemic and Beyond

    On March 13, 2020, then President Donald J. Trump announced an emergency declaration due to the outbreak of COVID-19 under the Stafford Act and the National Emergencies Act.31 This allowed the President to temporarily waive or modify certain requirements of the Medicare, Medicaid, and state Children’s Health Insurance Programs and of the Health Insurance Portability and Accountability Act Privacy Rule, as well as to authorize federal assistance for COVID-19 response efforts. Many permanent changes regarding digital behavioral healthcare have since occurred. 

    Commercial Health Plans

    In response to the widespread use of telehealth during the pandemic, by June 5, 2020  NCQA introduced telehealth for additional health quality measures: (1) diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medication; (2) cardiovascular monitoring for people with cardiovascular disease and schizophrenia; (3) diabetes monitoring for people with diabetes and schizophrenia; (4) adherence to antipsychotic medications for individuals with schizophrenia; and (5) follow-up after emergency department visit for people with multiple high-risk chronic conditions.32

    On December 1, 2020, to establish what quality telehealth looks like, NCQA proposed a telehealth module in health plan accreditation to help plans demonstrate that their telehealth networks provide “safe, equitable and coordinated care by credentialed physicians.”33

    Traditional Medicare

    As part of the 2021 Physician Fee Schedule, CMS has added the following behavioral health services to the ones that can be delivered via telehealth:

    • home visits for treatment of substance use disorders and co-occurring mental health disorders;
    • group psychotherapy;
    • psychological and neuropsychological testing;
    • care planning for patients with cognitive impairment;
    • domiciliary, rest home, or custodial services;
    • psychiatric collaborative care management with a psychiatric consultant.

    CMS added them after it determined that they are sufficiently similar to services already on the list of Medicare telehealth services.34

    The biggest change, however, may be the passage of the Consolidated Appropriations Act of 2021 (CAA), which contains a provision that will allow Medicare beneficiaries to utilize telehealth to diagnose, treat, or evaluate mental health disorders without the originating site restrictions.35 This law will become permanent after the public health emergency ends (CMS has waived originating site restrictions for the duration of the pandemic.) It will allow beneficiaries to receive telehealth services from their homes for mental health diagnosis, treatment, and evaluation.  This law, however, requires an in-person visit six months prior to the tele-mental health visit, and to continue in-person visits at regular intervals. This frequency will be decided by the Department of Health and Human Services (HHS) “by interim final rule, program instruction, or otherwise.”36 HHS has not announced when it will decide this frequency.

    In addition, CMS has permanently finalized changes regarding the delivery of home health services. Under these changes, home health care for a Medicare beneficiary can include remote patient monitoring and other services furnished via telecommunications technology or audio-only technology.37  This means that services such as care planning for patients with cognitive impairment (discussed above) can take place in the home.

    Medicare Advantage

    Changes have also occurred in Medicare Advantage. CMS now allows Medicare Advantage plans to count telehealth providers in psychiatry and primary care toward meeting CMS network adequacy standards.38    

    Pediatric Mental Health Care Access Program

    In addition, the American Rescue Plan provides $14 million to the Pediatric Mental Health Care Access Program.39  Signed into law on March 11, 2021, the American Rescue Plan is a $1.9 trillion COVID-19 relief package.40 The Pediatric Mental Health Care Access Program provides grants to states, subdivisions of states, Indian tribes, and tribal organizations to support mental healthcare telehealth access programs if such governmental entities match at least 20 percent of the federal funding.

    Medicaid

    State programs still vary, but some have made recent changes that affect behavioral digital healthcare.  For example, Arkansas passed a new law that permanently reimburses for counseling services, crisis intervention services, substance abuse assessments, mental health diagnosis assessments (for those 21 years and under), and group therapy (for those 18 years and over) delivered via telemedicine.41 This became law on April 8, 2021.42

    Fraud, Waste, and Abuse Enforcement

    The rapid expansion of telehealth in general and telehealth for behavioral health services has, not surprisingly, increased government scrutiny of these services. In February 2021, HHS’s Office of Inspector General (OIG) announced seven different telemedicine audits, including one that examines the use of telehealth to provide behavioral health services in Medicaid managed care.43 Another one looks at the use of Medicare telehealth services during the COVID-19 pandemic. The impetus of some of these evaluations seems to be to take a closer look at the challenges and opportunities in adopting telehealth and technology-empowered services to help assess whether some of the temporary changes in addition to the CAA will become permanent.44 Perhaps today Dr. Fry would not have faced the same False Claims Act allegations.   However, telemedicine remains an area at increased risk of fraud and abuse and the government is keeping a sharp eye out. For example, on September 30, 2020, the Department of Justice announced the largest healthcare takedown to date, resulting in $6 billion in alleged losses.45 It involved an alleged telemedicine scheme.46

    Additional Barriers

    Despite the promises of digital behavioral health, other barriers remain.

    Licensure

    For companies that offer therapy, licensure restrictions may impede them from scaling beyond their own jurisdiction. State and federal licensing regulations hinder many providers from treating patients in other states.

    Psychologists can join the Psychology Interjurisdictional Compact (PSYPACT), an interstate agreement that allows psychologists to practice telepsychology or offer temporary, in-person services across participating state boundaries without having to be licensed in other states. However, only 16 jurisdictions have enacted PSYPACT legislation: Arizona, Colorado, Delaware, District of Columbia, Georgia, Illinois, Missouri, Nebraska, Nevada, New Hampshire, North Carolina, Oklahoma, Pennsylvania, Texas, Utah, and Virginia.47 Psychiatrists as physicians can serve patients in other states through the Interstate Medical License Compact. Thirty states, the District of Columbia, and Guam have joined this compact.48

    The laws for the other behavioral health professionals – marriage and family counselors, clinical social workers, professional counselors, and addiction counselors – vary by state. For instance, Colorado permits out-of-state behavioral health professionals to practice in the state 20 days each year.49 Additionally, some states offer out-of-state reciprocity and endorsement. As an example, Michigan endorses clinical social workers who have practiced at least 4,000 hours post-degree supervised work in another state.50 California offers reciprocity for professional counselors.51 Arizona offers reciprocity for school counselors.52 Substance abuse counseling is not as standardized as the other mental health practices, with wide variability in licensing requirements among the states.53

    Standard of Care

    Another barrier is the varying standard of professional care. The standard of care is largely up to the states and often defined by the courts. In California, for example, the standard of care for physicians is the “reasonable degree of skill, knowledge and care ordinarily possessed and exercised by members of the medical profession under similar circumstances.... Geographical location may be a factor considered in making that determination…”54 In Louisiana, the standard of care for  licensed physicians, psychologists, medical psychologists, psychiatric mental health nurse practitioners, or public and private general hospital personnel is “exercising that degree of skill and care ordinarily employed, under similar circumstances by members of his profession in good standing in the same community or locality, and using reasonable care and diligence with his best judgment in the application of his skill….”55

    Because of this fuzzy standard, some states may consider services delivered via telehealth to meet the standard of professional care, while other states may not. Further, a clinician may be able to meet the standard of care in one state and not another.

    Interoperability

    Interoperability poses an additional hurdle. Most devices, including mobile apps, are independent silos of information that cannot effectively share information with the electronic health record (EHR) system that the healthcare team uses. This is magnified by the fact that behavioral health providers have the lowest adoption rate of EHRs, at 61.3 percent.56

    Clinical Effectiveness

    There is little information  about the clinical effectiveness of many mobile technologies, including those in behavioral health. A systematic review noted that only 4 out of 805 medication adherence apps had associated published evidence of clinical outcomes.57 A systematic review of eight randomized controlled trials investigating psychological outcomes from the use of mHealth apps to manage depression, chronic pain acceptance, insomnia severity, stress, or PTSD symptoms showed variations, with higher engagement associated with improved outcomes.58 Further research is required to investigate whether successful clinical outcomes are sustainable long term.

    Further, some stakeholders have expressed safety concerns with healthcare-related, consumer-facing third-party apps, including fears that these apps may be developed without expert involvement, an evidence base, or strong validation. For instance, one study found that just 10 percent of apps for depression include evidence-based principles.59 Moreover, there are concerns related to the information presented to the consumer, such as incorrect or incomplete information, content variation, and incorrect or inappropriate response to consumer needs. For example, an app for bipolar disorder incorrectly differentiated between condition types and suggested that bipolar disorder was contagious.60

    Removing Barriers: Federal Developments

    Federal legislation and other activity are pending that could remove many barriers to the widespread adoption of digital behavioral health.

    Virtual Peer Support Act

    In January 2021, U.S. Senator Catherine Cortez Masto (D-Nev.) re-introduced the Virtual Peer Support Act, a bill aimed at transitioning peer support programs onto telehealth programs to boost access.61 It would set aside $50 million in grants through the Substance Abuse and Mental Health Services Administration (SAMHSA) to help providers launch virtual care services and expand existing ones.62

    TREATS Act

    In February 2021, U.S. Representatives David B. McKinley (R-W.Va.), Ted Budd (R-NC), David Cicilline (D-RI), and David Trone (D-MD) re-introduced the Telehealth Response for E-Prescribing Addiction Therapy Services (TREATS) Act. The Act will allow certain controlled substances to be prescribed via an initial telehealth encounter for Medicare beneficiaries.63 It will also allow audio-only visits for Medicare beneficiaries with substance abuse disorders.64

    Tele-Mental Health Improvement Act

    Re-introduced in March 2021 by Senator Tina Smith (D-MN), the Tele-Mental Health Improvement Act would require commercial health plans to cover mental health and substance use disorder services both in-person and delivered via telehealth.65

    Additional Efforts

    There may also be developments in the ongoing effort to expand the use of medication-assisted treatment for substance abuse disorders. Advocates have been pressuring the U.S. Drug Enforcement Administration (DEA), under the authority of the SUPPORT Act, to finalize a special registration process for providers to use telemedicine to prescribe certain medications for substance abuse treatment.66 Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, providers must conduct an in-person examination before prescribing or otherwise dispensing controlled substances “by means of the Internet,” except when engaged in the practice of telemedicine. The definition of “practice of telemedicine” includes seven categories in which a provider can meet the in-person requirement through a virtual care platform – including under a special registration granted by the DEA. Section 3232 of the SUPPORT Act, signed into law October 24, 2018, amends the Controlled Substance Act (CSA) Section 311(h)(2) to require that no later than one year after enactment, the Attorney General, in consultation with the Secretary of HHS, promulgate final regulations specifying the circumstances in which a special registration for telemedicine may be issued and the procedure for obtaining the registration.67 As of yet, the Attorney General has not done so.

    Additional Expansion of Digital Behavioral Health Services

    There have also been developments in the private sector that can address gaps and increase access to care. For instance, digital behavioral health start-ups have proliferated. While the competition may seem fierce, many of these start-ups are providing services that did not previously exist. For example, emotional fitness therapy company Coa offers online mental health classes and workshops for workplaces. It champions a proactive approach to mental wellness, creating a “gym” for mental health. Online mental wellbeing start-up Real seems to take a similar approach. Says Real CEO Ariela Safira, "Though effective to some, one-on-one therapy is a deeply flawed model—it is financially inaccessible to the majority of Americans, it cannot scale at a rate that matches the demonstrated need for mental health care and the experience itself is unappealing to many people."68

    Therapy is also starting to serve more patient demographics. For instance, Yellow Chair Collective, founded in 2019, has started virtual support groups to lead discussions about the Asian American experience (as of this date, Talkspace offers no options in its drop-down menu for race issues when individuals select a therapist.)

    Conclusion

    The onset of the pandemic and the resulting stress and anxiety experienced by many Americans has illuminated the mental health gaps in care across the healthcare system. Moreover, a social and cultural shift in attitudes toward behavioral healthcare is taking place: seeking mental health care is losing its stigma. Together with the rise of digital behavioral health, a unique opportunity to improve the delivery of behavioral health services in the United States, including access to therapists, just may be presenting itself.

    1. SAMHSA, Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (September 2020).
    2. See HRSA, Shortage Areas, https://data.hrsa.gov/topics/health-workforce/shortage-areas (last accessed May 3, 2021).
    3. Wang, E. &  Zweig, C., A Defining Moment for Digital Behavioral Health: Four Market Trends, https://rockhealth.com/reports/a-defining-moment-for-digital-behavioral-health-four-market-trends/ (last accessed May 4, 2021); Chiu, N., Kramer, A., &  Shah, A., 2020 Midyear Digital Health Market Update: Unprecedented Funding in an Unprecedented Time, https://rockhealth.com/reports/2020-midyear-digital-health-market-update-unprecedented-funding-in-an-unprecedented-time/ (last accessed May 4, 2021).
    4. Teladoc, Teladoc Health Launches Mental Health Telemedicine Service (Oct. 21, 2020), https://www.teladochealth.com/newsroom/press/release/teladoc-health-launches-mental-health-telemedicine-service/.
    5. Reuters, Online Therapy Provider Talkspace to go Public Via $1.4 billion SPAC Deal , https://www.reuters.com/article/us-talkspace-m-a-hudson-executive/online-therapy-provider-talkspace-to-go-public-via-1-4-billion-spac-deal-idUSKBN29I1A2. A special purpose acquisition company (SPAC) is a company with no commercial operations that is formed strictly to raise capital through an initial public offering for the purpose of acquiring an existing company.
    6. Businesswire, Talkspace Launches Cigna Relationship, Marking a Milestone of 40 Million Insured Lives Covered for Virtual Mental Health Care (May 21, 2020),
      https://www.businesswire.com/news/home/20200521005142/en/Talkspace-Launches-Cigna-Relationship-Marking-a-Milestone-of-40-Million-Insured-Lives-Covered-for-Virtual-Mental-Health-Care.
    7. National Committee on Quality Assurance, Taskforce on Telehealth Policy Findings and Recommendations (September 2020).
    8. McGinty, E.E., Presskreischer, R., Han, H., & Barry, C.L., Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020, 324 Journal of the American Medical Association 93 (2020).
    9. Butterfield, S., Research Reveals Reasons Underlying Patient No-shows, ACP Internist (February 2009), https://acpinternist.org/archives/2009/02/no-shows.htm.
    10. Oak Street Health, What is behavioral health: Behavioral health v. mental health (May 20, 2021),
      https://www.oakstreethealth.com/what-is-behavioral-health-446277.
      There are a wide range of mental illnesses. They include anxiety disorders, autism spectrum disorder, intellectual disability, major depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder, as well as substance use disorders. They also range in severity. People with mental illnesses often require a range of services, from outpatient counseling to prescription drugs to involuntary psychiatric holds. Further, some people experience a mental illness for a short period of time, while others deal with them their entire lives. Some can experience an uptick in symptoms at certain times in their lives. Those with substance use disorders may fluctuate between abstinence and relapsing.
    11. Public Law 104-204.
    12. Public Law 110-343.
    13. Id.
    14. 42 U.S.C. § 18021 (a)(1)(B).
    15. Id. The other essential benefits are ambulatory patient services; emergency services; hospitalization; pregnancy, maternity, and newborn care; prescription drugs; laboratory services; preventive and wellness services; chronic disease management; and pediatric services. See https://www.healthcare.gov/coverage/what-marketplace-plans-cover/.
    16. U.S. Department of Health and Human Services, Mental health & substance abuse coverage, https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/ (last accessed May 29, 2021).
    17. 42 U.S.C. § 18031(j).
    18. Public Law 111-148.
    19. See 81 Fed. Reg. 18389 (Mar. 30, 2016).
    20. National Committee on Quality Assurance, Summary of Measures, Product Lines and Changes (2018), https://www.ncqa.org/wp-content/uploads/2018/07/20180101_HEDIS_Changes_2018.pdf.
    21. National Committee on Quality Assurance, COVID-Driven Telehealth Surge Triggers Changes to Quality Measures (2020), https://www.ncqa.org/programs/data-and-information-technology/telehealth/covid-driven-telehealth-surge-triggers-changes-to-quality-measures.
    22. 42 C.F.R. § 410.78(b).
    23. 42 U.S.C. § 1395(m.)
    24. 42 U.S.C. § 1395 (m)(4)(c).
    25. Public Law 115-78.
    26. Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, S.870, 115th Congress § 301 (2017-2018).
    27. Pennsylvania Department of Human Services, Guidelines for the Use of Telehealth Technology in the Delivery of Behavioral Health Services, OMHSAS-20-20 (Feb. 20, 2020).
    28. U.S. Department of Justice, Danbury Physician and Mental Health Practice Pay $36,000 to Settle False Claims Act Allegations (July 27, 2016), https://www.justice.gov/usao-ct/pr/danbury-physician-and-mental-health-practice-pay-36000-settle-false-claims-act.
    29. Id.
    30. Id.
    31. 42 U.S.C. §§ 5121 et seq.; 50 U.S.C. §§ 1601 et seq.
    32. National Committee on Quality Assurance, COVID-Driven Telehealth Surge Triggers Changes to Quality Measures (June 5, 2020),https://www.ncqa.org/programs/data-and-information-technology/telehealth/covid-driven-telehealth-surge-triggers-changes-to-quality-measures/.
    33. National Committee on Quality Assurance, Telehealth & Health Plan Accreditation (2020),
      https://blog.ncqa.org/telehealth-health-plan-accreditation/.
    34. Calendar Year 2021 Medicare Physician Fee Schedule Final Rule.
    35. Public Law 116-260. This law went into effect on December 27, 2020.
    36. Id.
    37. Centers for Medicare & Medicaid Services, CMS Finalizes Calendar Year 2021 Payment and Policy Changes for Home Health Agencies and Calendar Year 2021 Home Infusion Therapy Benefit (Oct. 29, 2020), https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-calendar-year-2021-payment-and-policy-changes-home-health-agencies-and-calendar-year.
    38. Centers for Medicare & Medicaid Services, Trump Administration Announces Changes to Medicare Advantage and Part D to Provide Better Coverage and Increase Access for Medicare Beneficiaries  (May 22, 2020), https://www.cms.gov/newsroom/press-releases/trump-administration-announces-changes-medicare-advantage-and-part-d-provide-better-coverage-and.
    39. U.S. Department of Health & Human Services, HHS Announces $14.2 Million from American Rescue Plan to Expand Pediatric Mental Health Care Access, https://www.hhs.gov/about/news/2021/05/20/hhs-announces-142-million-american-rescue-plan-expand-pediatric-mental-health-care-access.html (last accessed May 25, 2021).
    40. Public Law 117-2.
    41. To Ensure That Reimbursement In The Arkansas Medicaid Program For Certain Behavioral And Mental Health Services Provided Via Telemedicine Continues After The Public Health Emergency; And To Declare An Emergency, H.B. 1176, 93rd General Assembly, Regular Session § 1 (2021).
    42. Id.
    43. Office of Inspector General, Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care,  https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000397.asp (last accessed May 4, 2021).
    44. Office of Inspector General, Use of Medicare Telehealth Services During the COVID-19 Pandemic, https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000491.asp (last accessed May 4, 2021).
    45. U.S. Department of Justice, National Health Care Fraud and Opioid Takedown Results in Charges Against 345 Defendants Responsible for More than $6 Billion in Alleged Fraud Losses (Sept. 30, 2020),https://www.justice.gov/usao-sdga/pr/operation-rubber-stamp-major-health-care-fraud-investigation-results-significant-new.
    46. Id.
    47. See https://psypact.site-ym.com/page/psypactmap (last accessed May 4, 2021).
    48. See https://www.imlcc.org/participating-states/ (last accessed May 29, 2021) .
    49. Colo. Rev. Stat. § 12-245-217.
    50. Bureau of Professional Licensing, Social Work Licensing Guide (Apr. 25, 2017),https://www.michigan.gov/documents/lara/Social_Work_517676_7.pdf.
    51. California Association for Licensed Professional Clinical Counselors, Licensed Professional Clinical Counselor (LPCC): An Overview, https://calpcc.org/overview-california-lpcc (last accessed May 29, 2021).
    52. Arizona Department of Education, Requirements for the Standard School Counselor, PreK-12 Certificate (Apr. 29, 2019).
    53. Office of Assistant Secretary For Planning and Evaluation, U.S. Department of Health & Human Services, Credentialing, Licensing, & Reimbursement of SUD Workforce: A Review of the Policies and Practices Across the Nation, State Approaches to Licensing and Credentialing Substance Use Disorder Treatment Providers (Dec. 1, 2019), https://aspe.hhs.gov/report/credentialing-licensing-and-reimbursement-sud-workforce-review-policies-and-practices-across-nation/state-approaches-licensing-and-credentialing-substance-use-disorder-treatment-providers.
    54. Avivi v. Centro Medico Urgente Medical Center (2008), 159 Cal.App.4th 463, 470-471.
    55. LA. Rev. Stat. § 28:63.
    56. Yang N. & Hing E., Table of Electronic Health Record Adoption and Use among Office-based Physicians in the U.S., by Specialty: 2015 National Electronic Health Records Survey (2017).
    57. Ahmed, I., et al., Medication Adherence Apps: Review and Content Analysis, 6 JMIR mhealth and uHealth 3 (2018).
    58. Rathbone, A.L., et al., Assessing the Efficacy of Mobile Health Apps Using the Basic Principles of Cognitive Behavioral Therapy: Systematic Review. 19 J. Med. Internet Res. 11 (2017).
    59. Magee, J. C., Adut, S., Brazill, K., & Warnick, S., Mobile App Tools for Identifying and Managing Mental Health Disorders in Primary Care. Current treatment options in psychiatry, 5 Curr. Treat Options Psychiatry 3, 345–362. (2018).
    60. Akbar, S., Coiera, E., & Magrabi, F., Safety Concerns with Consumer-Facing Mobile Health Applications and their Consequences: a Scoping Review, 27 Journal of the American Medical Informatics Association 2, 330–340 (2020).
    61. Virtual Peer Support Act of 2021, S.157, 117th Cong. (2021-2022).
    62. Id.
    63. Telehealth Response for E-prescribing Addiction Therapy Services Act, S.340, 117th Cong. (2021-2022).
    64. Id.
    65. Tele-Mental Health Improvement Act, S.660, 117th Cong. (2021-2022).
    66. See https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/LT-DEA-SpecialTelemedicineRegistration-102620.pdf.
    67. Public Law 115- 271.
    68. Landi, H., Mental health startup Real lands $10M backed by Lightspeed and soccer star Megan Rapinoe (Apr. 7, 2021), https://www.fiercehealthcare.com/tech/mental-health-startup-real-lands-10m-from-lightspeed-and-athletes-megan-rapinoe-eric-kendricks.

    About the Author

    Nina Zhang, Esq. advises healthcare start-ups on reimbursement as well as fraud, waste, and abuse matters. She is based in Los Angeles, California, and can be reached at [email protected].