Maryland Law / How to Advocate for Specialty Treatment
In Maryland, if a consumer is seeking and advised to receive 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.
Some clients have been able to get “A Single Case Exception” in order to go out of network and still only pay their normal in-network copay. The insurance company covers the remainder of the therapist’s normal full fee. This makes out of network therapy as affordable to you as in-network therapy and allows you to choose a specialist of your choice.
Your insurance company may try to convince you that they have a specialist in their panel who can meet your needs. However, in the Washington, D.C. metro area, it is very unlikely that they will actually be able to find you Adherent or Comprehensive DBT services in-network. Therefore, I encourage you to call any therapist who they say provides in-network DBT and ask a few questions. Included here are some guidelines to help you determine whether or not the provider is actually offering adherent DBT.
How to tell if someone is providing Adherent DBT
Dialectical Behavior Therapy (DBT) consists of four components:
1. Weekly Individual DBT therapy with a DBT-trained clinician
2. Weekly DBT skills training – usually conducted in a group, but on occasion done on an individual basis.
3. Telephone coaching as needed to help the client use skills in daily life.
4. Clinician consultation group. DBT requires that the therapist in a consultation group with other DBT trained therapists.
Your insurance company may claim that they have clinicians in-network who "do DBT." However, very often when clients follow up with these clinicians, they have found that the clinician
a) does not do DBT and does not claim to do DBT
b) has minimal training in DBT, incorporates a few DBT skills into -DBT therapy, but does not claim to be a DBT therapist.
c) claims to "do DBT" but, in fact, has minimal training, doesn't separate out the skills component of DBT from the individual therapy session, and is not part of a DBT therapist consultation team.
d) Was trained in DBT and did practice it at one time, but does not currently offer a comprehensive program and doesn't practice DBT at this time.
Without all of the above components, it is not DBT!
It is worth asking specific questions to any provider that the insurance company has given to you 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 diary or daily report card?
6. Do you conduct chain analyses as part of therapy?
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 out-of-network treatment. I believe that the standard is that 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, and they also refuse to give you a single case exception, you can appeal that decision to the state insurance commissioner. If they do give you the name of an in-network therapist who appears to meet all the DBT criteria above, please let me know so I can meet and refer to them.
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.
Special thanks to The Metro DBT Consortium for their help putting together this information.
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