Single-Case Agreements: Getting Out-of-Network ABA at In-Network Cost

The problem this solves

ABA providers are often scarce. Your plan's in-network list may have no BCBA near you, a months-long waitlist, or no one experienced with your child's needs. Meanwhile a good out-of-network provider is available. A single-case agreement (SCA) is how you bridge that gap without paying full out-of-network prices.

What a single-case agreement is

An SCA (sometimes called a single-patient agreement or gap exception) is a one-time contract between your plan and a specific out-of-network provider to treat your child as if the provider were in-network. You pay in-network cost sharing (in-network copays and deductibles), and the plan pays the provider.

The key legal hook: if the plan's network is inadequate (no qualified, available in-network provider), the plan is obligated to arrange access. An SCA is the standard tool for that. This applies to PPOs as well as HMOs.

When you can ask for one

Ask for an SCA when any of these is true:

• No in-network BCBA / ABA provider within a reasonable distance.
• In-network providers exist but have no availability (long waitlists).
• In-network providers lack experience with autism or your child's specific

needs. A speech or behavioral license alone does not mean autism expertise; verify it.

• Your child is already established with an out-of-network provider and switching

would disrupt care.

Network-adequacy standards vary by state (built on a National Association of Insurance Commissioners model) and typically apply to plans sold on the exchange, though many states apply them to all plans they regulate. For a self-funded plan, check the plan manual for how it handles network adequacy, and lean on the argument that the network is insufficient. Some states set distance limits (for example, California limits mental-health travel to 15 miles from home for fully funded plans, versus 30 miles for medical services).

How to request one (step by step)

1. Call the in-network providers first and document the gap. Confirm in

writing that they lack availability or autism experience. This is your evidence.

1. Call the plan and state plainly: "Your network is insufficient. There is

no qualified, available in-network ABA provider. I need a single-case agreement to use [provider]." Log the date, the representative's name, and a tracking number.

1. Give the plan your out-of-network provider's details (name, NPI,

credentials, willingness to accept an SCA). Get names of qualified providers from other parents, support groups, or your child's physician.

1. Get the terms in writing before treatment starts: that you pay

in-network cost sharing, the approved rate, and the authorized period and number of hours. SCAs are usually time-limited and tied to the authorization period, so plan to renew alongside reauthorization.

1. If the plan resists, escalate. Report the inadequate network to your

state regulator (fully insured) or the Department of Labor / EBSA and your employer (self-funded). See erisa-self-funded-exemption and appeals-denials-external-review.

If you cannot get an SCA and must go out-of-network anyway

In a PPO you may still see an out-of-network provider and submit claims, but reimbursement can be low. Plans pay a percentage of what they call the "usual and customary" rate, and they sometimes set that figure far below the real market rate. Two defenses:

• Check the rate on FAIR Health (fairhealthconsumer.org), an independent

database of usual-and-customary rates built out of a lawsuit settlement. If the plan's reimbursement is far below FAIR Health's figure for your area and procedure, use that in an appeal.

• Request the plan's methodology. The plan is legally supposed to disclose

how it calculated the usual-and-customary amount. Ask for it, then challenge it.

If your plan is self-funded, tell your plan administrator or HR that the network is paying below market. Large employers have leverage with their administrators that individual members do not.

Bottom line

You are not stuck with an empty network. A single-case agreement gets you the right provider at in-network cost, and the plan owes it to you when the network cannot deliver. Document the gap, ask directly, get the terms in writing, and escalate to the regulator or EBSA if the plan drags its feet.