Maryland Law / How to Advocate for Specialty Treatment
In Maryland, if a consumer is seeking specialized therapy and there is no provider in-network who offers it, they are entitled to receive the service out of network with the in-network copay/deductible. The relevant statute of the Maryland Law is cited below.
Many patients 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 the same cost as in-network therapy for the subscriber.
Your insurance company may tell you that they have a specialist on their panel/in-network who can meet your needs. However, in the DC metro area it is very unlikely that they will actually be able to find you a DBT trained therapist who is in-network. 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 DBT.
How to tell if someone is providing DBT
Dialectical Behavior Therapy (DBT) consists of four components:
- Weekly Individual therapy with a DBT-trained clinician
- Weekly DBT skills training – usually conducted in a group, but on occasion done on an individual basis.
- Out of session phone 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.
Your insurance company may say 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
- Does not do DBT and does not claim to do DBT
- Has minimal training in DBT, incorporates a few DBT skills into non-DBT therapy, but does not claim to be a DBT therapist.
- Claims to “do DBT” but, in fact, has minimal training, doesn’t separate out the skills component of DBT from the individual therapy session, does not offer all components of DBT and/or is not part of a DBT therapist consultation team.
Without every one of the above components, it’s not DBT. It is worth asking specific questions to any providers that the insurance company has given to you to make sure that they are actually doing DBT.
- Do you do DBT?
- Do you provide both the individual component of DBT and the skills component?
- If so, are they taught at the same time or at separate times?
- Do you belong to a consultation team with other DBT trained therapists?
- Do you use a daily diary card?
If you find that the therapists whose names you have been given by your insurance company are not DBT therapists, go back to your insurance company and ask for them to authorize out-of-network treatment under the single case exception law (it’s important to use this specific language). Our clients tell us that they are successful when they appeal and act assertively. There are some exceptions to this law – please consider calling the Maryland Insurance Commissioner for additional information:
Maryland Insurance Commissioner
(410) 468-2000; 1-800-492-6116 (toll free)
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
- 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.