09 Dec Understanding Single Case Agreements: What to Know About Accessing Out-of-Network Care

December 9, 2025 ~ Health insurance networks can sometimes feel limiting, especially if you need a specialist or a certain type of care that isn’t available in-network. If you’re in this situation, you may have the option to request a Single Case Agreement (SCA) from your health insurance company.

This blog explains what SCAs are, when you can request one, and how they compare to a similar option called a gap exception.

What Is a Single Case Agreement?

A Single Case Agreement is a one-time contract between your health insurance company and a health care provider who is not in your insurance plan’s network. It allows you to see that out-of-network provider using your in-network benefits. That means you would only pay your regular co-pay or cost-share amount for the care that you receive.

When Can You Request a Single Case Agreement?

You may be able to request an SCA in the following situations:

• Specialized Treatment: You need a specific type of care that’s not available in-network
• Continuity of Care: You are already receiving care from an out-of-network provider and want to continue with them, especially if switching providers would disrupt your treatment.
• Geographic Barriers: There are no in-network providers close to where you live who can meet your health care needs.

How Do You Request a Single Case Agreement?

Requesting an SCA involves communication and documentation. Here's how the process usually works:

1. Talk to Your Provider: First, ask the out-of-network provider if they are willing to work with your insurance company. The provider must agree to the process.
2. Contact Your Insurance Company: Call the number on the back of your insurance card and ask about requesting a Single Case Agreement. Be ready to share the provider’s information.
3. Explain Your Situation: You’ll likely need to justify why you need to see this provider. For example:
   • Have you been seeing them already?
   • Is there no one in-network with the same specialty?
   • Is the nearest provider too far away?
4. Insurance Review and Negotiation: Your insurance company will decide whether to move forward and will negotiate with the provider.
5. Approval and Care: If approved, the agreement allows you to see the provider at the in-network rate for a specific period or type of treatment.

Can You Use an SCA with Medicare or Medicaid?

Medicaid: Some state Medicaid programs allow SCAs. Contact your State Medicaid agency or your Managed Care Organization (MCO) for more details. Each state has different rules and paperwork requirements. You may have to prove that the care is medically necessary.

Medicare: Traditional Medicare does not offer SCAs, because generally, you can go to any provider who accepts Medicare. However, there may be an option to request SCAs from a Medicare Advantage plan that has a specific network of providers for the plan.

What’s the Difference Between a Single Case Agreement and a Gap Exception?

While both Single Case Agreements (SCAs) and gap exceptions can help you access care from out-of-network providers, they are used in different situations.

A gap exception is typically used when there are no in-network providers available to meet your health care needs. In this case, the insurance company may allow you to see an out-of-network provider and still pay the in-network rate. This is usually a temporary solution until the insurance company can find and add providers to fill that gap in their network.

A Single Case Agreement, on the other hand, is usually requested by you or your provider when there are in-network providers available, but they may not offer the same level of specialty, or they may be too far away. An SCA allows you to see a specific out-of-network provider and pay in-network costs for your care. These agreements typically last only for the length of your treatment.

Key Takeaways

• A Single Case Agreement helps you get out-of-network care covered at in-network rates.
• They can be helpful if you need a specific provider, especially if you're already in treatment or live far from care.
• You must contact both your provider and insurance company—and explain why the agreement is necessary.
• Rules for SCAs may vary by state and insurance type, especially for Medicaid.

Need Help Navigating Health Insurance?

Triage Cancer offers free tools and resources to help you understand your rights and options:

• Health Insurance Resources
• CancerFinances.org Health Insurance Module
• Legal & Financial Navigation Program

You don’t have to navigate insurance alone.