Advocating for Out of Network Benefits
     

Several of our clients have had success getting single case exceptions for treatment of OCD, DBT, and some other mental health situations. Single case exceptions help the patient get reimbursed for all but their usual in-network copay from out of network providers. That helps make mental health, and in particular DBT, affordable for many people.

Maryland Law / How to Advocate for Specialty Treatment

In Maryland, if a consumer is seeking specialized therapy, they are entitled to receive it regardless of whether they have out-of-network benefits. What follows is the relevant statute of the Maryland Law. Please also carefully read the section on DBT.

Article Insurance §15–830.

(d) (1) Each carrier shall establish and implement a procedure by which a member may request a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel in accordance with this subsection.

(2) The procedure shall provide for a referral to a specialist or nonphysician specialist who is not part of the carrier’s provider panel if:
(i) the member is diagnosed with a condition or disease that requires specialized health care services or medical care; and
(ii) 1. the carrier does not have in its provider panel a specialist or nonphysician specialist with the professional training and expertise to treat or provide health care services for the condition or disease; or

2. The carrier cannot provide reasonable access to a specialist or nonphysician specialist with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable delay or travel.

(e) For purposes of calculating any deductible, copayment amount, or co-insurance payable by the member, a carrier shall treat services received in accordance with subsection (d) of this section as if the service was provided by a provider on the carrier’s provider panel.

(f) A decision by a carrier not to provide access to or coverage of treatment or health care services by a specialist or nonphysician specialist in accordance with this section constitutes an adverse decision as defined under Subtitle 10A of this title if the decision is based on a finding that the proposed service is not medically necessary, appropriate, or efficient.

(g) Each carrier shall file with the Commissioner a copy of each of the procedures required under this section.

Your insurance company may offer you that they have a specialist in their panel who can meet your needs. Just because a therapist or provider says they work with OCD, DBT, and some other conditions does not mean they have the specialized training making them qualified to treat the condition. Particularly with DBT. Although this is a long and grueling effort, we encourage you to check the training and qualifications of any in network. In particular, DBT is very specific – here are some questions to ask to determine if you whether or not the provider is actually offering DBT.

Does the provider offer the four components of Dialectical Behavior Therapy (DBT)?

  • Weekly Individual DBT therapy with a DBT-trained clinician
  • Weekly DBT skills training – usually conducted in a group, but on occasion done on an individual basis.
  • Telephone coaching as needed to help the client use skills in daily life.
  • Clinician consultation group. DBT requires that the therapist participate in a consultation group with other DBT trained therapists.

Without all of the above, it is not DBT.

It is worth asking specific questions to any provider to make sure that they are actually doing DBT.

1. Do you consider yourself to be a DBT therapist?

2. Do you provide both the individual component of DBT and the skills component?

3. If so, are they taught at the same time or at separate times?

4. Do you belong to a consultation team with other DBT trained therapists?

5. Do you use a daily diary or daily report card?

6. Do you conduct chain analyses as part of therapy?

The Internatioal OCD Foundation has some tips for finding the right therapist. You can find them at this link: https://iocdf.org/about-ocd/treatment/how-to-find-the-right-therapist/

The Treatment And Research Advancements for Borderline Personality Disorder offers the following tips to finding the right DBT Therapist at this link: https://www.tara4bpd.org/new-page-71/

Now what?

If you find that the therapists whose names you have been given by your insurance company are not DBT therapists, you can go back to your insurance company and ask for authorize for out-of-network treatment. By law, your insurance company has 48 hours to find you a specialist who you can see that is a reasonable distance from where you live.

If your insurance company cannot find you an in-network DBT therapist and DBT has been recommended as the treatment of choice for you, they should offer you a single case exception. If they refuse to give you a single case exception, you can appeal that decision to the state insurance commissioner.

To access your patient portal account, please click on the link: www.valantmed.com/Portal/cpe