Generic Information About Out-of-Network Insurance & Single Case Agreements
Nearly one in five U.S. adults experiences a mental illness each year, but nearly half of adults coping with these conditions do not receive any treatment.[1]
Insurance limitations are one of the major barriers to mental health treatment access. Around 30% of adults report not getting care because their insurance does not cover enough or does not cover services at all.[2]
Many people with an active insurance plan do not find an appropriate in-network provider for the care they need, and they can not afford the out-of-pocket costs associated with going out-of-network. A single case agreement is a practical solution to this problem.
Mission Connection Healthcare advocates for your case for a single case agreement if your insurer does not cover the costs of your treatment at our facility.
On this page, you will find everything you need to know about out-of-network coverage and single case agreements for mental health treatment.
What Does “Out-of-Network” Mean in Mental Health Care?
In the U.S., insurance companies build their networks of doctors and treatment centers that agree to charge according to mental health insurance utilization rules.[3] A treatment centre outside that network is not tied to those restrictions. In other words, “out-of-network” means the treatment center you are going to is not under contract with your insurance company.
Many insurance plans still cover out-of-network mental health, but at much higher rates than “in-network” providers. You may have a higher deductible before your coverage begins, or your plan may pay only a portion of the cost based on what it considers a “reasonable” rate rather than the full amount. In some cases, you pay upfront and then get reimbursed by your insurance after submitting a claim.
Out-of-network care gives you access to programs that are not limited by insurance rules, so it is more flexible. So people are more likely to go out-of-network for mental health care than for medical or surgical care because their in-network options are limited.[4]
What Is a Single Case Agreement?
A Single Case Agreement (SCA) is a one-time exception your insurance company makes to cover treatment at a provider that is not in its network. It allows you to receive mental health care at an out-of-network center while your insurance agrees to cover the treatment as if it were in-network.
To put it simply, it’s a temporary contract for your specific case.
You can not treat an SCA as a general contract that adds the provider to the insurer’s network. It applies only to your current treatment episode for a defined period at only the discussed level of care.
Before finalizing the terms of the SCA, the insurance company and the provider negotiate the payment rates. They agree on how much the insurer will pay per session, per day, or per service. The negotiated rates between the two parties replace the usual out-of-network billing structure for your case.
Once an SCA is in place, your financial responsibility follows your in-network benefits instead of your out-of-network benefits. So, you will have lower out-of-pocket costs and won’t likely have to pay anything upfront.
When Can a Single Case Agreement Be Approved?
A Single Case Agreement is approved when your insurance company determines that in-network options cannot meet your clinical needs. Such situations include:
- The treatment you need is not offered by any in-network provider, for example, an addiction program with a specific dual diagnosis focus.
- There are no in-network options within a reasonable distance from where you live.
- The existing in-network providers do not have openings, and a long wait time is risky for your mental health.
- The available in-network providers are not appropriate for your age group, gender identity, religious or cultural background, or clinical condition.
- There is clear evidence that the available in-network options could negatively affect your treatment.
- Continuity of care, e.g., you are already in treatment and your insurance changes, or you are stepping down from a higher level of care to a lower one at the same facility.
The Steps to Request a Single Case Agreement
To request a Single Case Agreement, you need to coordinate with your treatment provider and your insurance company. Here is a step-by-step approach to requesting one.
1. Verify Your Out-of-Network Mental Health Coverage
You need to know, very clearly, what your current insurance plan covers as out-of-network benefits. Call the member services number on your insurance card and ask them the following questions about your specific plan:
- “Does my plan include out-of-network benefits for mental health and substance use treatment?”
- “What is my out-of-network deductible, and how much has been met?”
- “What is my in-network deductible?”
- “How does my plan define “medical necessity” for mental health treatment?”
- “What is my coinsurance for in-network vs. out-of-network care?”
- “What are my out-of-pocket maximums?”
- “Does my plan allow Single Case Agreements or network gap exceptions?”
- “If it does, will I need to pay upfront and seek reimbursement, or will the provider be paid directly?”
Keep a record of the call with the date and the representative’s name.
2. Submit a Prior Authorization
Prior authorization is a formal request sent to your insurance company asking for approval before you begin your treatment. It is needed for the insurer to understand the level of care you need and where you plan to receive it.
Every Single Case Agreement will not require prior authorization, but many insurance providers do. The insurer needs to confirm that your treatment is medically necessary before they will review an exception to use an out-of-network provider.
If your plan requires prior authorization, your provider will submit it on your behalf. They will evaluate your mental health symptoms and give you a diagnosis along with a recommended treatment plan. The plan includes what kind of care you should get, such as residential or outpatient treatment, the expected length of stay, the type of services, and so on.
All clinical notes are submitted to the insurance company, which compares the request to its internal guidelines to decide if it can approve your request.
3. Provide Justification for a Mental Health Insurance Exception
Once it’s established that your treatment is medically necessary, you need to justify why it must be done with an out-of-network provider. We’ve discussed the circumstances where an SCA is justified earlier.
Your provider needs to explain why available in-network options cannot meet your needs. The request should include the diagnosis, your symptom severity, treatment history, and any prior attempts at care. The document will also list the records of calling in-network providers with no availability, or a lack of providers within a reasonable distance, with names and dates.
The treatment center you want the Single Care Agreement for must show how its program meets your needs. The more specific the information, the stronger the case.
4. Negotiate Your Terms
Negotiating the terms of an SCA happens between the treatment provider and the insurance company.
Both parties agree on how much will be paid for care, either a daily rate for residential treatment or a per-session rate for outpatient care. The agreement specifies the exact scope of services covered, such as individual or group therapy sessions, medical visits, medication management if you have a co-occurring psychiatric diagnosis, and other services.
The insurer approves treatment for a defined period of time. Once all terms are set, your costs are aligned with your in-network benefits, including deductibles, copays, or coinsurance.
5. Await Approval
If you have submitted your request, fulfilling all the requirements of your insurance providers, you now just need to wait for a formal decision.
Standard requests can take several days to a few weeks. If your situation is urgent, make sure your provider requested an expedited review for your application.
If approved, the insurer will issue an authorization describing how they will cover your treatment. If your application does not meet the insurer’s requirements, they may deny it.
Single Case Agreements With Medicaid and Medicare
Single Case Agreements can be used with Medicaid because many Medicaid plans have very limited provider networks for mental health and addiction treatment. In some cases, there are no in-network options available at all for certain levels of care.
Many Medicaid plans also do not offer out-of-network benefits. So, an SCA is the only way for the plan to cover care at a specialized facility.
The state Medicaid plan may approve a one-time agreement with an out-of-network provider so you can access medically necessary treatment.
But the situation might be more restrictive with Medicare. Traditional Medicare does not allow Single Case Agreements in the same way as private insurance or Medicaid does.
Medicare Advantage plans, however, which are offered through private insurers, can allow some exceptions that work similarly to Single Case Agreements. These are called “gap exceptions.”
[5] If approved, the plan agrees to cover care at an out-of-network provider because there is no suitable in-network option. But gap exceptions are harder to secure than a Single Case Agreement with private insurance or Medicaid.
How Long Does a Single Case Agreement Last?
A Single Case Agreement is approved for a specific period of care based on your treatment plan and medical need, so it will last for the length of your current treatment episode.
Your agreement will define the specific timeframe in a set number of days in residential treatment or a set number of sessions in an outpatient program.
But if you need more time in therapy than what was decided at the time of application, your provider will have to request an extension of the SCA to continue your coverage.
If you have completed your treatment once and then you relapse, for which you need another course of treatment, your original agreement can not carry over. You will need to request a new SCA.
What Happens if Your Single Case Agreement Request Is Denied?
If your SCA is denied, it means your insurance company has decided, based on the information provided, not to approve the request at this time. But you can appeal their decision.
An insurance appeal is a formal request asking your insurer to review and reconsider their decision. The reasons for denial, in most cases, are:
- The insurer believes the requested level of care or provider is not medically necessary based on their guidelines.
- That the treatment is considered “experimental.”
- The request did not include enough clinical detail.
- If the insurer denied the exception and expects you to use in-network providers.
If your request is denied, your provider can speak directly with the insurance company’s medical director to explain why the treatment is necessary. This should be done within 24 to 48 hours after the denial. If you requested an SCA for residential treatment, you can request a fast-tracked appeal within 72 hours.
When an expedited appeal is denied, you can go through the insurer’s formal internal review process. In this process, you will submit additional documentation and a detailed explanation of why the denial should be overturned.
An independent third-party review can also be requested as per most U.S. state policies. The external review is legally binding on the insurance company.
Mission Connection Healthcare Can Help You Navigate Insurance
Mission Connection Healthcare provides a compassion-driven, evidence-based clinical program for mental health treatment. Our services are available in-person and via telehealth at our treatment centers in California, Washington, and Virginia.
Mission Connection is in-network with many major insurance providers across the country. We also accept out-of-network coverage and have experience working with people to pursue Single Case Agreements when needed.
If you are considering treatment, reach out to the admissions team to get a free, confidential insurance verification. Even if we are not in-network with your insurance provider, we can defend your case for a Single Case Agreement for care at one of our facilities.
