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.