You may have heard that insurers almost never cover Borderline Personality Disorder (BPD) treatment because the Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies it as an Axis II personality disorder. Because Axis II personality disorders are considered constant and non-acute, most insurance carriers reject treatment claims.
If you or a loved one is suffering with BPD, the categorization of the condition as “non-acute” can be disheartening and the idea of having to get treatment without financial help daunting. However, depending on your insurance carrier and your plan, you may have some options.
Verify Your Recommended Treatment
Speak with your therapist or clinician and identify the variety and scope of therapy and treatment they recommend to help treat your BPD. While insurers do not typically cover Axis II personality disorders, they may cover treatment for co-occurring disorders such as substance abuse, depression, Bipolar Disorder, eating disorders, and anxiety disorders.
Your mental health professional will often recommend treatment for these disorders when submitting your claim to your insurer. Of course, treating these disorders (when present) is a crucial therapeutic step if you want a lasting recovery from Borderline Personality Disorder. Just be sure that treatment of your BPD does not go ignored.
By seeking coverage for co-occurring disorders rather than the overall Borderline Personality Disorder diagnosis, you may have some success getting your claims paid by your insurer. Check with your insurer carrier in advance before assuming you have coverage just because you’ve been diagnosed with another disorder such as depression, Bipolar Disorder, substance abuse, an eating disorder, or an anxiety disorder.
Get Educated on Your Insurance Coverage
If your insurance does, in fact, cover Borderline Personality Disorder therapy or a BPD treatment center, you would be well advised to keep on top of your insurer and become educated on the exact extent of the coverage they are willing to provide. Insurers often limit the number of sessions allowed for certain therapies or may refuse to cover particular treatment modalities, such as Dialectical Behavior Therapy (DBT), regardless of their effectiveness or proven validity.
Although dealing with insurers can be a daunting task, it is a necessary one if you are to seek proper treatment for your Borderline Personality Disorder by a qualified therapist or BPD treatment center. By educating yourself on what types of therapies and treatment centers are available and how your insurance coverage assesses claims and determines benefits, you will be in a better position to get the care you need.
Our DBT-informed Program incorporates aspects of other treatment modalities, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), Adlerian Therapy, etc., while holding true to the core DBT principles and skills. The program at Integrative Counseling and Congruent Counseling is one of the only programs around that can incorporate our full DBT-informed program and addiction treatment programs. This has been very effective for clients who cannot maintain clean time or who have dual diagnoses who have not been able to maintain a healthy lifestyle.
Each of these components of our program is what makes us stand out from other groups, which may offer only one group per week or just individual therapy. We tailor the program to each client’s needs; hence the four levels of treatment as described. We are also different because the individual and family therapy portion of the program can be covered in-network with most commercial insurance companies. No other program in the area offers this.
Successfully Getting a Single Case Agreement/Network Exception Request
We at the DBT-Linehan Board of Certification™ (DBT-LBC™) are committed to helping all individuals receive quality DBT services regardless of financial situation. We understand that the process of identifying high fidelity providers and programs who accept insurance can be an extremely difficult task, in the midst of what is already an incredibly overwhelming time. If you are unable to find an in-network provider and/or program or are struggling to assess whether a provider is actually qualified to provide DBT as designed and researched, we have created the following to help you in that process. There are clinicians and programs that provide quality DBT that may not be certified by DBT-LBC™, but those that have been certified by DBT-LBC™ have met certain high certification assessment standards and that often helps in getting your insurance company to agree to cover the treatment. If there are no DBT-LBC™ certified clinicians or programs within your physical vicinity, we encourage you to make sure that any clinicians who claim to provide DBT meet all of the other criteria stated in this document before proceeding with getting an SCA.
View Frequently Asked Questions
Often if a client is seeking specialized therapy and there is no provider or program in-network who offers it, they are entitled to receive the service out-of-network with the in-network copay/deductible.
Many clients have been able to get a “Single Case Exception” or a “Single Case Agreement” for DBT 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, it is very unlikely in most situations, that you will actually be able to find a DBT-LBC™ certified clinician (or even a trained DBT therapist) or certified program who is in-network. What we suggest is that you call any therapist or program who your insurance company says 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 comprehensive DBT.
Dialectical Behavior Therapy (DBT) consists of four components:
- Weekly individual therapy with a DBT-trained clinician, (a minimum of 40 DBT specific hours of training from a reputable training provider) and preferably a DBT-LBC™ certified clinician or a clinician within the DBT-LBC™ certified program. The structure of each individual session should be created by a client’s recorded answers on a form called a “diary card” which is filled out daily.
The highest standard in assessment of DBT delivery is the DBT-Linehan Board of certification™. To confirm certification of your DBT provider or program by the DBT-Linehan Board of Certification™, go to the website of the DBT-Linehan Board of Certification™: https://dbt-lbc.org/index.php.
- Weekly DBT skills training–usually conducted in a specialized group, but on rare occasion done individually in a separate session focused solely on skills training.
Adherent skills training requires that both teaching of new material AND a review of assigned weekly home-work is conducted. Research indicates that outcomes for clients are best if they complete 2 full cycles of the program’s skills training curriculum.
- In between session phone coaching–needed to help the client use skills in daily life and avoid higher levels of care.
- Clinician Consultation Team meeting–DBT requires that the therapist participate in a weekly consultation team meeting with only other DBT trained therapists.
***Note–in DBT continued participation in treatment requires that clients are improving on structured assessments like the diary card. This is different than many other treatments where clients stay longer in the therapy if they are NOT improving.
Without every one of the above components, it’s not DBT
It is worth asking the following specific questions to any providers that the insurance company has given to you to make sure that they are actually providing comprehensive DBT.
- Are you or your program certified by the DBT-LBC™?
- Do you provide DBT treatment?
- What was your training for providing DBT?
- Do you provide both the individual therapy component of DBT and the skills component?
- If so, is the skills training offered in a group setting and how long does group last each week?
- How long does your program take to complete 1 cycle of skills training?
- Do you allow a client/family to complete the skills training curriculum 2 times?
- Is continued participation in your DBT services based on some type of ongoing assessment of symptom improvement?
- Do you provide phone coaching between sessions as needed? Are there any limits placed on phone calls or between session contacts?
- Do you belong to a consultation team that meets weekly and includes only other DBT trained therapists?
- Do you use a daily diary card?
- What adaptations have you made to the research supported methods of providing DBT? Why were those adaptations necessary?
Very often when clients ask “DBT in-network” clinicians the above questions 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 4 components of DBT, does not offer research supported methods for meeting the 4 required components, and/or is not part of a DBT therapist consultation team.
If you find that the therapists or program 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 a single case exception or single case agreement. Some states actually have laws that will help support you in these requests. Our clients tell us that they are most successful when they appeal and act assertively. Do not expect to get an immediate “yes” or approval for your request. It may take going up the chain a bit to find someone who is familiar with DBT.
Here is a possible script for you to use when calling your insurance:
First say, “I would like to request a Single Case Agreement/Exception to see an Out-of-Network provider and/or program who is certified by Dialectical Behavior Therapy-Linehan Board of Certification™ (or specializes in Dialectical Behavior Therapy).” (It is best to say the whole name of Dialectical Behavior Therapy instead of DBT because insurance companies often think people are saying CBT).
Second say, “I have tried to find a Dialectical Behavior Therapy- Linehan Board of Certification™ program/clinician who is in-network with (name of insurance plan) and have not found any. I cannot afford to see an out-of-network provider without a single case agreement because I do not have out of network benefits/I have out of network benefits with a high deductible and co-insurance.”
This may be the point where the insurance company gives you names of providers in-network who “do DBT.” You will then need to call those names and ask the questions that were discussed above to assess whether they really are trained DBT clinicians providing DBT therapy. After you call the names given to you and you do not find a DBT clinician in-network, call the insurance company back and continue with the following:
Third say, “I have called the clinicians and programs that you provided to me on (say the date of your initial call) and upon speaking with them discovered that they are not certified by DBT-Linehan Board of Certification™ or trained in Dialectical Behavior Therapy and/or do not follow the researched and evidence based model of Dialectical Behavior Therapy in their practices.”
Fourth say, “Through my own research I found a clinician and/or program who is certified by the DBT-Linehan Board of Certification™. I have asked if (name of clinician referred to in previous statement) will consider a single case agreement and they have said yes. What is the next step I need to take?”
Once you start the process for getting a single case agreement/exception you may be asked by the insurance company to “justify” why you need this specialized treatment in order for them to agree to cover it. Many insurance companies will require that you have the symptoms or behaviors associated with Borderline Personality Disorder, emotional dysregulation and/or behavioral dysregulation (e.g. self-harm, suicidal behavior and thoughts, psychiatric hospitalizations, etc.). That is because DBT has been shown by research to reduce these issues and reduce the need for other higher levels of care (e.g. partial hospital). As a result, DBT is a therapy shown to reduce overall expenses for the insurance companies in the long-term. This cost reduction has been confirmed by research on ADHERENT DBT PROGRAMS ONLY that deliver all four components discussed above in a manner that is consistent with the design and research of the treatment.
Many insurance company representatives are not familiar with different types of therapies and do not know the difference between them. If you are running into roadblocks with a particular insurance company representative it may help to say the following, “Is there a representative or supervisor I can speak with who has specific experience and knowledge of Dialectical Behavior Therapy?” It is common that once a person knowledgeable about the treatment modality becomes part of the process that things start moving along more smoothly.
Please know that the process of getting an SCA differs widely between states and from insurance company to insurance company. If you are having difficulties or have questions after trying these steps, please read the FAQs, ask a DBT-LBC™ Certified provider in your state or contact DBT-LBC™ for assistance in identifying a provider who might be able to answer your questions.
For a printable version of the script, please click one of these links: brief version of the script, or full script.
The legislative committee of the DBT-LBC™ would like to share our greatest appreciation for those organizations and clinicians who have gone before us in helping to support patients and their families in getting Single Case Agreements for DBT! These include Emotions Matter Inc. https://emotionsmatterbpd.org/resources2 [emotionsmatterbpd.org] and their publication “Utilizing Single Case Agreements to Access Treatment for Borderline Personality Disorder: A Strategy to Support Health Care Consumers and Clinicians” (2017), and Judi Sprei, PhD, Britt Rathbone, LCSW-C, Brian Corrado, PsyD of the DBT Metro Consortium www.dbtmetro.com [dbtmetro.com]
Frequently Asked Questions
Why can’t I find a DBT-LBC™ Certified clinician or program that is in-network with my insurance?
First, as you have probably gathered from the information on this website, DBT is a highly specialized treatment that requires extensive training, ongoing education and that the clinician works with a team of other DBT trained clinicians. This specialization means that there are fewer trained DBT therapists than there are general therapists. Also, because of the time, energy, and cost of providing DBT, many therapists do not participate with insurance companies, Medicaid, or Medicare due to the low reimbursement that they provide, something that DBT-LBC™ is also trying to change!
Second, there are currently only a small number of DBT-LBC™ Certified Clinicians and Programs compared to non-certified clinicians and programs. This is due largely to the fact that DBT-LBC™ clinician certification only came into effect in 2014, and DBT-LBC™ certification of programs started in the middle of 2017.
We expect that as time goes by the number of DBT-LBC™ Certified Clinicians and Programs will grow significantly. We also hope to work towards the long-term goal of increasing reimbursement so that more DBT-LBC™ Clinicians and Programs will become in-network within insurance companies, Medicaid and Medicare.
What is the difference between using my out of network benefits and attempting to get a Single Case Agreement/Network Exception?
The primary differences are related to the amount of effort the consumer will need to put in to get the services paid for AND the amount of money the consumer will have to lay out for services. Here are some additional differences:
Out of Network Benefits
- Out of network benefits are a part of many insurance plans and reimburse a percentage of the total charges for therapy services either directly to the therapy provider or to the consumer. Using out of network benefits does not require that you get a particular provider authorized with them before receiving treatment (but may require pre-authorization for particular service types). Also, there is usually a deductible that must be met first before the insurance company starts paying out of network benefits.
- Depending on the particular therapy provider, the out of network reimbursement process can take any of the following forms:
- The consumer may be required to pay the full fee for services up front and then submit an invoice to their insurance company showing payment made to receive a reimbursement check for the allowed percentage.
- Some providers may be willing to wait for payment until the unpaid invoice is sent in by the consumer to the insurance company and the consumer receives reimbursement. After receiving the reimbursement check the consumer will pay the therapy provider.
- Other providers may be willing to submit invoices for out of network reimbursement directly to the insurance company and wait until they receive a reimbursement check. Once they receive the check they will provide the consumer with an invoice for the balance owed.
- Each consumer’s financial situation and insurance plan differ, and for some people using out of network benefits is not an option because:
- The insurance plan does not have an out of network reimbursement allowance
- The deductible is very high and a consumer cannot afford it
- Even once the deductible has been met, the percentage reimbursed for out of network benefits leave a balance with the therapy provider that the consumer cannot afford
Single Case Agreement/Network Exception
- Consumers are allowed to file for a single case agreement/network exception request with their insurance company so that an out of network provider is paid on a one case basis as if that provider were in-network. If a consumer is successful in getting one of these agreements, then the insurance company will pay a set fee for each service that is agreed upon by the provider. Sometimes this ends up being the provider’s normal fee and sometimes it is a reduced fee that is negotiated between the provider and the insurance company. With a single case agreement/network exception request, the consumer is required to pay their normal co-pay/co-insurance and CANNOT be billed for any remaining balance that results from the insurance company paying less than the provider’s full fee.
- Single case agreements/network exception requests require that the consumer (or provider) apply for this agreement and receive authorization BEFORE it goes into effect. Charges for any services attended prior to the application for a single case agreement/network exception request fall on the consumer. As such, it is important to start the process as soon as possible once the decision is made to pursue this route.
- Most single case agreements/network exception requests are denied on the first attempt and will need to be appealed. This is usually because the insurance company claims that in network providers already exist who can provide the same services (see the single case agreement/network exception scripts for how to respond to these denials).
- Single case agreements/network exception requests are authorized for a specific date range AND a specific number of services. Extensions will need to be filed if a consumer needs more services beyond those authorized in the initial single case agreement/network exception request. There are no guarantees that an extension will be granted and additional appeals may be required.
I followed the single case agreement/network exception scripts and have called all of the in-network providers who “do DBT” according to my insurance company and none of them are DBT-LBC™ Certified nor do they provide DBT in the way you describe the treatment on your website. My insurance company denied my request even after I shared this information with them. What is my next step?
Your next step is to follow the appeals process that your insurance company has in place. Sometimes you will need to get the help of a patient advocate assigned through your insurance company. Sometimes you or the provider you want to see will have to complete additional paperwork and send in additional clinical information. You or the provider may be asked to speak with an insurance company clinician to plead your case. Whichever next step is required by your particular insurance company, it makes sense to keep pushing forward! Many times a single case agreement/network exception request is authorized with only one additional appeal.
What if I keep getting denied for a single case agreement/network exception request after multiple appeals?
We know this can be frustrating and discouraging. Unfortunately, some insurance plans will not approve single case agreements/network exception requests without a significant fight from the consumer (and some will never agree to one). Some consumers have even attempted to get a lawyer or other advocate involved. There is no one route that promises success. Using the single case agreement/network exception scripts can help, as can responding to specific requests from insurance companies related to data on the “efficacy of comprehensive DBT” and soon to be published data on the increased success of DBT treatment when it is provided adherently. It is also important to know your rights within your particular state. Some states, like Maryland, have laws in place that require insurance companies to agree to single case agreements/network exception requests in certain situations.
Does DBT-LBC™ offer any scholarships for DBT treatment if I don’t have out of network benefits and I can’t get a single case agreement/network exception?
At the current time DBT-LBC™ does not provide scholarships for DBT treatment. However, there are some organizations that provide scholarships for treatment if a consumer has a particular diagnosis like an eating disorder or Complex-PTSD or has experienced particular traumas in their life. It may be helpful to google these scholarship opportunities and apply if you meet their criteria.
I live in an area where there are no DBT-LBC™ Certified clinicians or programs or the DBT-LBC™ Certified clinicians and programs are not taking any new clients. I have found a clinician/program that is not certified by DBT-LBC™ and they seem to be meeting all of the criteria you mention in the single case agreements/network exception script. Should I try to get a single case agreement/network exception with that clinician/program?
We at DBT-LBC understand that the availability of DBT-LBC™ Certified Clinicians and Programs is still very limited. We expect that as time goes by the number of DBT-LBC™ Certified Clinicians and Programs will grow significantly. We are committed to making the process for certification accessible to clinicians and programs so that the availability will increase. Please know that clinicians and programs who have undergone the intensive process required for certification have met high assessment standards in providing DBT treatment in a manner consistent with the research on the efficacy of the treatment. Clinicians and programs that are not yet certified by DBT-LBC™ may provide high quality DBT treatment that meets all of the criteria listed in the single case agreements/network exception scripts. If you are unable to find a DBT-LBC™ Certified clinician or program, clinicians and programs providing adherent DBT services in line with the criteria listed in the single case agreements/network exception scripts are the next best option. However, getting a single case agreement/network exception request authorization specifically for DBT with a clinician or program that does not meet the criteria for adherent DBT may ultimately hurt future consumers by having an insurance company pay for a treatment that is not supported by research and may not have the successful outcomes of adherent DBT. Insurance companies may then become less willing to agree to cover adherent DBT because of unsuccessful outcomes of non-adherent DBT and the fact that they may not know the difference between the two.