What is a single case agreement?

A single case agreement (SCA) is a one-time contract between your health insurer and a specific out-of-network provider, for you specifically. It lets the insurer cover that provider at a negotiated in-network rate, so you can keep seeing the therapist you need without paying full out-of-network prices.

It's one of two ways out-of-network mental health care becomes affordable. The other is a network gap exception, and for private-pay care that's the more common outcome by far. An SCA is the exception, used when a plan won't grant in-network benefits without a rate contract, or when you need your cost fixed in advance.

How a single case agreement works

Normally, if your therapist isn't in your plan's network, you pay out-of-network rates, sometimes the full fee, with little or no reimbursement. An SCA changes that. Your insurer agrees, for your case only, to treat that specific provider as if they were in-network: they negotiate a rate with the provider, cover their share, and you pay standard in-network cost-sharing instead of the out-of-network price.

Two things make this valuable to you. Your cost drops to the in-network level, and because there's an agreed rate, the provider can't bill you for the balance above what the insurer pays.

It's worth understanding what that asks of your provider, because it's the reason an SCA isn't the default. The negotiated rate is usually below their standard fee, and the contract obliges them to accept it as payment in full, so they absorb the difference. They also take on billing your insurer directly, which a private-pay practice is set up to avoid.

Single case agreement vs. network gap exception

These get confused constantly, and the difference decides what your care looks like. Most cases resolve as a gap exception, and for private-pay care, that's usually the outcome you want.

• A network gap exception is the benefit decision. Because your plan lacks an adequate in-network option for your need, your insurer applies in-network benefits to your out-of-network provider. You pay your provider's fee directly and your plan reimburses you at your in-network level.
• A single case agreement is the rate contract. It locks a negotiated price and caps your cost at in-network cost-sharing up front, and it protects you from balance billing, but it requires your provider to accept that rate and bill your insurer directly.

The honest version: a gap exception gives you reimbursement relief: you still pay the full fee, and how much comes back depends on your plan's allowed amount. An SCA gives you cost certainty up front, at the cost of changing how your provider gets paid. We'll tell you which one your case is heading toward before you commit.

When you can get one

Insurers are most likely to grant an SCA when there's a real reason the network can't serve you, such as:

• No adequate in-network provider for your specific need, including no one who speaks your language, shares your cultural background, or has an opening within a reasonable distance or wait.
• Continuity of care. You're already in treatment that's working, and switching to an unfamiliar in-network provider would set back real progress.
• A specialized need your plan can't match in-network.
• An urgent situation where waiting for an in-network opening isn't safe or reasonable.

For mental health specifically, federal parity law also requires that access to behavioral health care be no more restrictive than access to medical care, which strengthens these requests.

What it means for your costs

With an approved SCA, you pay in-network cost-sharing for a provider who was out-of-network. Those sessions also count toward your in-network deductible and out-of-pocket maximum, so once you reach your in-network cap, covered sessions are fully paid for the rest of the plan year. And because the rate is agreed in advance, there's no balance bill.

A gap exception works differently, and it's worth knowing the difference before you assume which one you're getting. There, you pay your provider's full fee and claim reimbursement at your in-network benefit level, calculated against your plan's allowed amount rather than the fee itself. Anything above that allowed amount isn't covered, and only the allowed amount counts toward your out-of-pocket maximum, so the cap moves more slowly than it would under an SCA.

How to request one

The process usually looks like this: document that your plan has no adequate in-network option for your need, get a letter of medical necessity from your provider, submit a formal request to the insurer, and negotiate the rate once they agree in principle. Insurers authorize care in blocks (often around 12 sessions), so longer courses are renewed as treatment continues.

This is the part Inclara handles. We build the documentation, submit the request, and push your insurer for the gap exception (or for a single case agreement where your plan requires one) so you can focus on your care. You only pay if your coverage is approved.

Frequently asked questions