Single case exception experiences

[Anonymous]

I am being told that federal health plans don’t need to abide by the single case agreement/exception law for a doctor recommended mental health program (DBT) for my child. The problem is that basically no one has this program in network for young children (not teens).

I’d to gather all my data points before going down this long road (BCBS Federal).

Does anyone have any experience or advice to share on negotiating this?

Thanks in advance.

[Anonymous]

I have never heard of such a law.

[Anonymous]

SIL was able to get a number of OON providers approved with federal BCBS for my niece, including PHP and DBT.

[Anonymous]

Who gave you that information?

[Anonymous]

Before you start down this path, is the provider willing to accept the single case agreement? Usually if they are on panel with another insurance company, just not yours, this is not an issue. If however, they don’t accept insurance and you are trying to get a SCA, this is much harder as the provider has to be willing to accept the insurance reimbursement rate.

[Anonymous]

These SCAs are hard. Under a different plan, we got a mental health group in the DC area to reach an SCA with BCBS. The mental health group told us we had to pay a deposit over and above what we owed under the SCA.

BCBS still treated the claims like there was no SCA in place at all, and we owed tens of thousands. Now, we are fighting to get our deposit back, which was an overestimate, and get BCBS to pay for the SCA as they agreed.

Good times. Be careful out there.

[Anonymous]

Anonymous wrote:These SCAs are hard. Under a different plan, we got a mental health group in the DC area to reach an SCA with BCBS. The mental health group told us we had to pay a deposit over and above what we owed under the SCA.

BCBS still treated the claims like there was no SCA in place at all, and we owed tens of thousands. Now, we are fighting to get our deposit back, which was an overestimate, and get BCBS to pay for the SCA as they agreed.

Good times. Be careful out there.

Important warning. I have a friend who got her kid accepted into a PHP on a single case agreement that was either not honored as agreed or that my friend didn’t understand. My friend ended up with a bill that was almost 40% of her take home pay for a year. Appeals dropped a few thousand off but she had to borrow money to pay it.

[Anonymous]

What are you trying to treat with DBT and what reasons are you choosing that method over others? Are there other available therapies that are covered by your insurance?