Medicaid Single Case Agreements

Medicaid Single Case Agreements: What are They and Why are They Important?

Medicaid is a federal and state-funded program that provides health coverage to millions of low-income families, elderly people, and people with disabilities. It is a crucial safety net for people who cannot afford private health insurance, and for those who have complex medical needs. However, navigating the Medicaid system can be challenging for both patients and providers alike. One issue that often arises is the need for single case agreements.

What are Single Case Agreements?

A single case agreement (SCA) is a contract between a health insurance company and a healthcare provider for a specific patient who is not covered by the insurer`s usual network of providers. SCAs are typically used when a patient has a complex medical condition and needs treatment from a specialist who is not part of the insurer`s network, or when the patient lives in a remote location or travels frequently. SCAs allow the patient to receive the care they need while ensuring that the provider is reimbursed for their services.

Why are SCAs Important for Medicaid Patients?

For Medicaid patients, SCAs are often required when their primary care physicians refer them to specialists outside of their network. Medicaid contracts with a limited number of healthcare providers, and not all specialists may be available in an area. For example, a Medicaid patient with a rare genetic disorder may need to see a geneticist who is not in the Medicaid network. In this case, the patient`s primary care physician would request an SCA to allow the patient to see the out-of-network geneticist.

Similarly, Medicaid patients who live in rural or underserved areas may need to see specialists in nearby cities who are not in the Medicaid network. In this case, an SCA would allow the patient to receive care from the out-of-network provider without incurring additional costs.

How Do SCAs Work for Medicaid Patients?

The process of obtaining an SCA for a Medicaid patient can be complex. First, the patient`s primary care physician must request the SCA from the Medicaid managed care organization (MCO) that provides the patient`s coverage. The MCO will review the request and either approve or deny it based on whether the requested specialist is deemed medically necessary and cost-effective.

Once the SCA is approved, the patient can receive care from the out-of-network provider, and the provider can bill the MCO for their services. However, the reimbursement rate for out-of-network providers is often lower than in-network providers, so the out-of-network provider may bill the patient for the difference between the reimbursement rate and their usual fee.


SCAs are an essential tool for Medicaid patients who need specialized care outside of their network. While the process of obtaining an SCA can be complicated, it is crucial for ensuring that patients receive the care they need and that providers are reimbursed accordingly. Providers who treat Medicaid patients should be familiar with the SCA process and be prepared to advocate for their patients when necessary. And for Medicaid patients, understanding the SCA process can mean the difference between receiving the care they need and going without it.