Single case agreements [SCAs] have emerged as an essential tool for connecting patients’ needs with insurance coverage limitations. SCAs are now crucial in ensuring patients have access to care, mainly when network restrictions and changing reimbursement models exist. SCAS can benefit both patients and healthcare providers. However, one must understand how they work, when they’re appropriate, and their implications in today’s healthcare landscape. Let’s examine what SCAs mean for patients and providers in 2025.
What Is a Single Case Agreement?
A single case agreement is a contract between an out-of-network healthcare provider and a health insurance company. If a patient wants to receive care but the required healthcare provider is not covered under their health plan, they can use the single case agreement.
The SCA is often used in situations where the patient needs specialized healthcare that is not available in their plan or where the patient is in a geographic area with limited network providers. SCAs are tailored contracts that often include in-network rates and negotiated terms.
Why Are SCAs More Relevant in 2025?
There are various reasons single-case agreements will be highly relevant for patients and healthcare providers in 2025:
1. Demand for Specialized and Niche Care
Nowadays, medicine has become highly specialized. Patients now have rare diseases, complex mental health needs, and neurodiverse conditions. This causes them to look for providers with rare expertise, and these might not be included in their insurance networks. With SCAs, they can still get affordable, insurance-covered care from an out-of-network provider.
2. Health Equity and Cultural Competency
Some patients who are from historically marginalized communities might require affirming care, which means they need out-of-network providers; these can include Indigenous, immigrant, LGBTQIA+, and BIPOC populations. SCAs allow these individuals to access care, even if their usual provider does not cover it.
3. Telemedicine and Cross-State Care
Telehealth continues to expand, and more patients seek healthcare from providers outside their state or service area. SCAs allow you to access remote healthcare providers and still get affordable care.
Benefits for Patients
Single case agreements come with diverse advantages for patients, especially those with complex health conditions and unique personal circumstances. Patients can access specialized providers with these agreements, especially if in-network options are insufficient. An autistic child can benefit from a therapist who specializes Applied Behavior Analysis [ABA], but these are usually not included under an insurance provider. But with SCAs, they can access this care, even if they’re out of network.
Patients moving states or changing their insurance plans mid-treatment can use SCAs so they don’t have to change their providers even with a new insurance company. This is especially important in mental health care.
Without insurance, some healthcare services are costly. SCAs ensure that the patient can pay in-network rates or a reduced fee for services that would have been unaffordable.
Benefits for Healthcare Providers
Healthcare providers can also benefit greatly from single-case agreements, especially since they have previously been limited by insurance companies. Now, they can serve patients even if they are not in network with certain insurance companies, and they can also receive proper compensation through SCAs.
Although the reimbursement might not be as high as out-of-network rates, SCAs still allow for a negotiated fee. This reflects the provider’s expertise and overhead instead of default in-network rates.
SCAs also allow providers to expand their service footprint, especially when offering telehealth to underserved regions. SCAs often require providers to demonstrate medical necessity or effectiveness before the insurance company approves. This allows for clinical documentation and will strengthen the case for this medical service to be included under the insurance company in the future.
Challenges to Using SCAs
There are some challenges that come with SCAs today, as many providers and patients attempt to take advantage of them.
1. Administrative Burden
Securing an SCA can be time-consuming. Healthcare providers need to submit detailed documentation, wait for insurance approval, and negotiate terms. In some cases, it can take weeks for this to be approved.
2. Temporary Solutions
SCAs are usually short-term solutions, as they are only signed for a particular patient or a limited number of sessions. This can create uncertainty for the patient and the provider on long-term care.
3. Lack of Standardization
Every insurance company has different policies and protocols for SCAs. This can lead to confusion, delay,s and denials when getting these agreements approved.
4. Risk of Denials
Insurers might also deny SCA requests if they think an in-network provider could meet the patient’s needs, even if the match is imperfect.
SCAs as a Powerful Tool
Single case agreements are a reliable tool to ensure patients are not denied the care they genuinely need. They meet the demand for specialized health care, health equity, and telemedicine. SCAs offer access to specialized providers, continuity of care, affordable health for patients, and opportunities to serve non-network patients to providers. For patients and providers, SCAs are essential for quality care.
