What Is A Single Case Agreement?

What you may be wondering, “what is a single case agreement?” if your insurance plan or doctor has thrown the term out as an option. A Single Case Agreement (SCA) is a one-time contract between an insurance company and an out-of-network provider so the patient can see that provider using their in-network benefits.

It is an exception to the network so that the patient will only have to pay their routine in-network co-pays for sessions after meeting their in-network deductible (if any). The fee per session that will be paid by the insurance company is negotiated by the insurance company and the provider as part of the SCA.

An SCA can be justified when:

• The outpatient provider/treatment program has a clinical specialty, which is not available among any in-network provider
• The in-network provider does not treat people of your age, gender, or religious preference
• The geographical location of the patient does not have any in-network providers
• A patient who has recently changed their insurance plan or is stepping down to a different level of care at the same facility (continuity of care)
• All in-network providers are full and have no availability
• There is proof that the available in-network providers are inappropriate or would cause harm (e.g. the patient is transgender and they need a provider with expertise in transgender expertise)
• If a plan does have out-of-network benefits, the deductible, out-of-pocket max, and/or co-pay may be too costly financially

Single Case Agreements With Medicaid and Medicare

SCAs can be obtained and are often needed with Medicaid plans, when there are often no in-network options and no out-of-network benefits are available. This is especially common in Medicaid plans when residential level-of-care is being requested.

SCAs are not possible with traditional Medicare. However, they are possible for some Medicare Advantage plans (sometimes referred to as gap exceptions). It will be more difficult to obtain a SCA with Medicare than private plans or Medicaid plans. If your Medicare Advantage plan is willing to do a gap exception, it is sometimes difficult to identify a treatment center that is willing to work with Medicare for this exception.

How Do I Set Up an SCA?

SCAs are typically negotiated directly between your healthcare provider and your insurance company. When you first reach out to your healthcare provider for treatment, you can ask them whether they would be willing to negotiate a SCA with your insurance company.

Be prepared to provide details about your medical history and whether you have received eating disorder treatment in the past. The stronger your case is that your chosen provider is the best care for you, the more likely your insurance company will agree to a SCA.

Here are the specific steps you need to take:

1. Start by contacting Member Services at your insurance company (will often be on the back of your insurance card) to request a list of in-network (INN) providers/treatment facilities specializing in eating disorders.
2. If there are no INN providers available, ask if you have out-of-network (OON) benefits. Many insurance plans do not have OON benefits, so it is important to check. A Single Case Agreement can be requested if you have OON benefits to be paid at an INN rate.
3. While on the phone with your insurance company, ask to be assigned a Behavioral Health Case Manager, if you do not already have one. This is a free enrollment within your policy. Tell the representative on the call this is URGENT and contingent on you finding immediate treatment – this will hopefully get you a Case Manager to contact you sooner rather than later. If you haven’t heard back in 1-2 weeks, do not be afraid to call back and be a squeaky wheel!
4. Your Case Manager will be your advocate from within the insurance company and your main point of contact going forward. They will help connect you to INN and OON resources.
5. If you do not have OON benefits, let your Case Manager know you are in need of a Single Case Agreement, and ask them if it is possible within your insurance plan. Inform your Case Manager you have “exhausted all resources” and “there are no known (PHP/IOP/Residential) eating disorder facilities INN” with your plan that meets BLANK needs. They will help guide you on next steps once it is determined that a SCA is possible.
6. If you are starting a Single Case Agreement, once you have spoken with your Case Manager, call the admissions department at eating disorder treatment centers to ask if they will work with your insurance to request a SCA (let them know you have a Case Manager and if they said SCA was possible). This will often vary by plan, and certain facilities will not work with Medicaid. Start with in-state or the closest facilities, if possible – these are sometimes more likely to be approved for a SCA.
7. Once you find a treatment center willing to work with your insurance, the treatment center will work with your Case Manager, or the appropriate contact provided, to guide you through next steps in the process.
8. If you have outpatient providers (therapist/dietitian/psychiatrist/PCP), it may be helpful to have them communicate with the treatment center to provide more rationale for your recommendation to a higher level of care and the need for a SCA. This may be helpful in gathering more information for insurance to meet “medical necessity criteria” for a SCA.

How Long Does an SCA Last?

SCAs typically last for the length of your treatment. However, if you complete treatment with your provider and decide to resume treatment at a later date, you would need to negotiate a new SCA with your insurance company.

Learn More About Navigating Insurance Coverage and Eating Disorders

Insurance can be difficult to navigate and questions like “what is a single case agreement?” are totally normal! To help you understand your benefits and how to get the help you need, we have a few other helpful resources: