A single case agreement is a contract a health plan writes for one patient and one episode of care, so that an out-of-network program is paid on terms close to in-network ones. It is discretionary, it is requested by the program rather than by you, and it is not a right.
It is also not the first thing to try. Before anyone asks for one, the ordinary route should have been tested: verify your insurance with an admissions team, find out what the plan’s own network holds at the rung you need, and see whether an in-network option is genuinely available in an acceptable timeframe. Our page on whether insurance covers rehab covers the benefit itself and the network question this sits inside.
What a single case agreement is
One patient, one episode, one negotiated rate.
Normally a plan pays an in-network facility at a contracted rate the facility has agreed to accept as payment in full, and pays an out-of-network facility a percentage of its own allowed amount, leaving the rest with the member. A single case agreement puts a specific admission on something closer to the first footing without the facility joining the network.
Three things typically sit inside one: the rate the plan will pay, the level of care and the number of days or sessions authorized, and the member’s cost share, which is usually set at the in-network level rather than the out-of-network one. That third element is the reason it matters. It is the difference between a percentage of a known number and an open-ended gap.
What it is not is a promise about the whole stay. An agreement is written against an authorized episode, so a step down from residential care to a partial hospitalization program or to outpatient rehab is normally a fresh conversation rather than something already covered.
When an insurer will consider one
When its own network cannot deliver the care its member needs, in time, within a reasonable distance.
That is the shape of every argument that works, and everything else is decoration. A plan is more likely to agree when the requested rung is one its network thins out at — medical detox and residential treatment more often than outpatient care — and when the clinical case for that rung is documented rather than asserted.
Two features of the law sit behind that. Marketplace plans must cover mental health and substance use disorder services, and they may not apply annual or lifetime dollar limits to them [1]. And network composition is not outside parity: under the Mental Health Parity and Addiction Equity Act, a plan that covers mental health and substance use care may not apply harsher limits to it than it applies to medical and surgical care, and that reaches prior authorization and step therapy as well as visit and day caps [2]. The scope is worth knowing: it applies to non-federal governmental plans with more than 50 employees, to group health plans of private employers with more than 50 employees, and to the individual market [2]. Plans from small employers are not covered directly; they get comparable protection through the Affordable Care Act’s essential health benefits requirement.
The arguments that do not work are worth naming too, because people spend weeks on them: preference for a particular program, a recommendation from a friend or a therapist without a clinical rationale tied to the rung, and reputation. None of those is a network-adequacy argument.
Network adequacy arguments that work
Specific, documented, and about the plan’s network rather than about the program you want.
The case has four parts, and the strongest requests carry all of them.
The rung is clinically indicated. Placement is a clinical exercise with published criteria behind it. SAMHSA’s TIP 45 describes a system of care that “matches patients’ clinical needs with the appropriate care setting in the least restrictive and most cost-effective manner”, and notes that the American Society of Addiction Medicine built its Patient Placement Criteria as “a consensus-based clinical tool for matching patients to the appropriate setting and level of care” [3]. An assessment that names the rung and says why a lighter one is not appropriate is the foundation.
The network does not contain it, for this person, now. This is where the work is. A list of in-network facilities the program or the member actually called, with dates, the person spoken to, and what each said — no bed, no admission for this substance, no capacity for a co-occurring mental health condition, a wait of several weeks — is the evidence. A general assertion that “there is nothing in network” is not.
Distance and timing. How far the nearest in-network alternative is, and when it could admit. A bed available in three days at an out-of-network program can be clinically better than a bed in three weeks in network, and that comparison belongs in the request in writing.
Continuity, where it applies. Where somebody is stepping down from a stay that this program already delivered, or has a documented history with a specific program, the continuity argument is real. It is weaker on its own than the first three.
Who negotiates it, and how long it takes
The facility’s utilization review or admissions department does, with the plan’s case manager. You are not the negotiator.
Your part is smaller and still important: sign the consents that let the program share the clinical record with the plan, make sure the plan has your correct member details, and keep your own log of every call. Ask the admissions team who at the program is handling it and ask for their name.
Timing varies by plan, by rung and by urgency, and anybody quoting a universal figure is guessing. What is predictable is what slows it down: missing clinical documentation, a consent form that has not been signed, and an authorization request submitted for the wrong level of care. Ask the program on day one what it still needs from you.
Two questions make the wait bearable. What happens clinically if this takes longer than the situation can wait? And what is the fallback if the answer is no? A program that cannot answer the second question has not thought about it.
Ask admissions to check the network position first
The Recovery Village Umatilla in Umatilla, Florida provides medical detox, inpatient treatment for substance use, inpatient rehab for mental health, a partial hospitalization program, outpatient programming and aftercare planning. Our admissions team checks network status rung by rung and runs the assessment in the same call, which is what any single case agreement request has to be built on.
See treatment options in Florida
Verify your insurance
The Recovery Village Umatilla is part of our family of treatment centers. See the Recovery Village Umatilla campus.
What the agreement covers, and for how long
A defined rung, a defined number of days, and a defined rate. Read all three before anybody travels.
Ask for the agreement in writing and ask four questions of it. Which level of care does it authorize? How many days or sessions? What is the member cost share, and is it set at the in-network level? And what happens at the end of the authorized period — does it extend by concurrent review, or does it lapse?
That last question is the one that catches people. A single case agreement usually runs to the end of an authorized episode, and continuing beyond it means the same concurrent review any in-network stay would face: evidence that the person still meets criteria at that rung, and evidence of progress. Plan the step down before the agreement runs out rather than after.
Ask the program the matching questions. What is billed inside the agreement and what is billed outside it — medications, laboratory work, a psychiatric assessment, transport? And what is your position financially if the plan declines to extend mid-stay? Our page on what rehab costs sets out the variables that move the figure, and our carrier pages for Aetna, Cigna and Humana describe how each structures behavioral health benefits.
One thing an agreement is not is a federal protection. The No Surprises Act is real but narrower than people assume: CMS describes it as protecting you from unexpected out-of-network bills from emergency room visits, from “non-emergency care related to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center”, and from air ambulance services [4]. A planned admission to a freestanding residential program you chose in advance is in none of those categories, which is exactly why the agreement has to be negotiated rather than assumed.
If the request is refused
Appeal, and note that the clock is short.
A refusal is a plan decision, and plan decisions are appealable. You must file an internal appeal “within 180 days (6 months) of receiving notice that your claim was denied” [5], and the insurer must complete it “within 30 days if your appeal is for a service you haven’t received yet”, or “within 60 days if your appeal is for a service you’ve already received” [5]. Where the situation is urgent, an internal appeal and an external review request may be filed at the same time, and a final decision “must come as quickly as your medical condition requires, and at least within 4 business days after your request is received” [5].
If the internal appeal fails, an independent external review follows. A written request must be filed “within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied” [6]. Standard external reviews are decided “no later than 45 days after the request was received”, and expedited ones “no later than 72 hours, or less, depending on the medical urgency of the case” [6]. The outcome binds the plan: your insurer “is required by law to accept the external reviewer’s decision” [6].
Appeals are documentation exercises. The call log, the list of in-network facilities contacted with dates and names, and the clinical assessment are what the reviewer reads, which is why they are worth keeping from the first phone call rather than assembled afterward.
Keeping the admission moving while it is negotiated
Do not let the paperwork decide the clinical timetable.
Ask three questions while the negotiation runs. Can an assessment and a bed hold proceed now, and on what terms? What is the self-pay position for the days before an agreement is reached, in writing? And is there an in-network program that can start the same care sooner, even if it is not the preferred one?
That third question is not defeatism. Where two options are both clinically reasonable, the one that can start this week is often the better clinical answer, and the assessment travels with the person either way. Our walkthrough of how to get into rehab covers the sequence, our directory of our treatment centers lists the campuses we run, and our nationwide facility directory is the wider map.
Keep the clinical question and the financial question separate in your own head. The first is what rung somebody needs and when. The second is who pays for it. They are answered by different people, on different timetables, and letting the second set the pace of the first is how a week becomes a month.
Frequently Asked Questions
What is a single case agreement, in plain terms? A contract a health plan writes for one patient and one episode of care, so that an out-of-network program is paid on terms close to in-network ones. It usually sets the rate, the level of care and the number of days authorized, and puts the member’s cost share at the in-network level. It is discretionary rather than a right, and it does not make the facility part of the network.
Who asks for one, me or the program? The program. Its utilization review or admissions department makes the request to the plan’s case manager and supplies the clinical documentation behind it. Your part is signing the consents that let the record be shared, giving the correct member details, and keeping a log of every call with dates and names. Ask the admissions team who is handling the request and get their name.
How long does a single case agreement take? It varies by plan, by rung and by urgency, so no page can give a reliable number. What is predictable is what slows it down: missing clinical documentation, an unsigned consent form, and a request submitted for the wrong level of care. Ask the program on day one what it still needs from you, and ask what the clinical fallback is if the answer takes longer than the situation can wait.
Does a single case agreement cover the whole stay? Usually not. It normally runs to the end of an authorized episode at a named level of care, so continuing beyond it means the same concurrent review an in-network stay would face. Ask in writing which rung it authorizes, how many days, what the cost share is, and whether it extends by review or lapses. Plan the step down before it runs out.
What if the insurer refuses one? Appeal it, and quickly. An internal appeal must be filed “within 180 days (6 months) of receiving notice that your claim was denied” and completed by the insurer “within 30 days if your appeal is for a service you haven’t received yet”. If that fails, an independent external review follows, filed within four months, and the insurer “is required by law to accept the external reviewer’s decision”.
Sources
- HealthCare.gov. Mental health and substance abuse health coverage options. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
- Centers for Medicare and Medicaid Services. The Mental Health Parity and Addiction Equity Act (MHPAEA). CMS. https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity
- Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment, TIP 45, Chapter 2: Settings, Levels of Care, and Patient Placement. SAMHSA, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64109/
- Centers for Medicare and Medicaid Services. Medical Bill Rights: What is the No Surprises Act?. CMS. https://www.cms.gov/medical-bill-rights
- HealthCare.gov. Internal appeals. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- HealthCare.gov. External review. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
This page is for general information and is not medical advice. Only a licensed clinician who knows your history can tell you what is right for you. If you or someone you know is in immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
