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Medicare Mental HEalth Reimbursement Proposal

Updated: Aug 2

Medicare payment for mental health Digital Therapeutics (DTx)!?!

Today marks a giant leap forward for the digital therapeutics industry.


The 2025 Medicare Physician Fee Schedule Proposed Rule was just released and includes a proposal to establish new codes for Digital Mental Health Treatment (DMHT) devices (ah yes a new acronym, because healthcare doesn’t have enough yet).


The rule won’t be finalized until November, and there is an open comment period for the next 60 days, but here is a brief overview of what the proposed rule says:

- The DHMT device will need to be FDA cleared and intended to treat or alleviate a mental health condition

- It will need to be prescribed or ordered by a clinician as part of a behavioral health treatment plan

- There will be a new code established GMBT1 for the supply of the DMHT device - this means clinicians will ‘buy and bill’ the device - buy it from the manufacturer, furnish it to the patient, and then submit a claim to Medicare

- Payment for the code will be set by the Medicare Administrative Contractors (MACs)

- There are two additional codes modeled off of and priced based on RTM treatment management codes that reimburse the provider for their time managing the patient, reviewing their treatment response, etc.


Why is this a big deal?

- Until now, there has not really been a standardized way that a category of digital therapeutics could get covered and paid as part of the traditional healthcare system. (Feel free to argue with me in the comments about A9291)

- Medicare sets a precedent that the other payers follow. Assuming this proposal is finalized, we can expect commercial payers to follow suit in the coming years (with some convincing from the industry, no doubt)

- Even though the initial focus is mental health, this expands the Overton window, so to speak, and I suspect there will be a lot of comments submitted and progress made on DTx for other therapeutic areas in the coming months and years


Link to MPFS proposed rule in comments.


I would love to hear your thoughts and questions.

hashtag#digitaltherapeutics hashtag#digitalhealth




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