Single Case Agreement for ABA Therapy: How to Use an Out-of-Network Provider

A single case agreement for ABA therapy is a one-time contract between your health plan and an ABA provider outside its network, written for your child alone. It lets your child see that provider while you pay what you would pay in network. Families usually go looking for one after hearing the same thing from every in-network clinic: no openings, a waitlist measured in months, or nobody who serves your area.

Washington law gives families in many plans real leverage here. This guide explains how single case agreements and gap exceptions work, which rules apply to your plan, and how to ask.

What is a single case agreement?

It is a contract for one patient. Your plan and the out-of-network provider agree on:

• the payment rate for each ABA service,
• which services and how many units are approved (for example, the assessment, direct therapy, and parent training),
• the start and end dates, and
• your cost sharing, which should match what you would pay in network.

Without one, an out-of-network ABA provider either bills you directly or bills the plan’s out-of-network benefit, if your plan has one. Out-of-network ABA can cost a family thousands of dollars a month at full price. Our guide to how much ABA therapy costs has the numbers.

Single case agreement vs. gap exception

The two terms get mixed up because they usually come as a pair.

• A gap exception (also called a network gap exception or network exception) is the plan’s decision that its network cannot meet your child’s needs, so it will cover an outside provider at in-network cost sharing.
• A single case agreement is the contract that makes the exception work. It sets the rate and terms between the plan and that provider.

Plans use their own language. UnitedHealthcare’s network gap exception form says it applies when there are not enough providers “in a local area or in a specific specialty.” The form is submitted by the provider. It asks for the referring in-network doctor, the CPT codes and units, how long treatment is expected to last, and the reason for the request. It also requires a prior authorization case to be opened first.

Cigna calls its version a network adequacy provision. Other plans just say “out-of-network exception.” Ask for it by whatever name your plan uses.

Does Washington require my plan to cover out-of-network ABA?

It depends on what kind of plan you have. This is the most important thing to find out first.

Fully insured plans regulated by the state

Individual plans, small-group plans, and many employer plans are regulated by the Washington Office of the Insurance Commissioner (OIC). For these plans, WAC 284-170-200 requires networks to make covered services accessible “in a timely manner” and “without unreasonable delay.”

When the network does not have a provider for a covered service, the same rule says the plan must arrange that service from a provider within reasonable proximity “at no greater cost to the enrollee than if the service were obtained from network providers.” That is the legal basis for a single case agreement.

The rule also sets a timeline. After a referral to a specialist, a nonurgent appointment must be available within 15 business days. ABA is not named in the rule, but behavioral health is part of what networks must cover adequately. If every in-network ABA provider has a six-month waitlist, write that down. It is your evidence.

When a plan knows its network falls short, it files an alternate access delivery request with the OIC. Even then, it must provide covered services at in-network cost to you.

Self-funded employer plans

Many large employers in Washington pay claims themselves and hire an insurance company only to run the plan. These self-funded plans fall under federal law (ERISA), not state insurance rules. The OIC says plainly that it does not regulate them, and that people who work for a very large employer probably have one.

Your card may still say Premera, Regence, Aetna, or Cigna. Ask HR or member services: “Is our plan fully insured or self-funded?”

A self-funded plan is not required to follow WAC 284-170-200, but it can still grant a gap exception, and many do. Federal mental health parity law also applies to how these plans manage behavioral health benefits. The federal agencies paused enforcement of the newer parts of the 2024 parity rule in 2025, but the underlying parity law still applies. Questions about a self-funded plan go to the U.S. Department of Labor’s benefits advisors at 866-444-3272.

Apple Health (Medicaid)

Federal Medicaid rules require managed care plans to cover needed services out of network, “adequately and timely,” when their own network cannot provide them, and at no greater cost to you. That is 42 CFR 438.206. For the Apple Health steps that come before ABA, including the Center of Excellence evaluation, see does Medicaid cover ABA therapy.

How to ask for a single case agreement

1. Confirm ABA is a covered benefit on your plan. An exception gets you access to a provider. It does not add a benefit your plan excludes.
2. Document the network gap. Call the in-network ABA providers your plan lists. Write down the date, the provider, and what they said: no openings, a waitlist and how long, does not serve your city, does not offer the setting your child needs. Three to five calls is usually enough to show a pattern.
3. Call member services and use the words. Say: “No in-network ABA provider can serve my child within a reasonable time or distance. I am requesting a network gap exception and a single case agreement with [provider name].” Get a reference number for the call.
4. Bring the provider in. The out-of-network provider usually submits the plan’s request form and negotiates the rate. Ask the provider whether they are willing to do this before you rely on it. Not every provider accepts single case agreements.
5. Get the prior authorization started. The plan still has to approve ABA as medically necessary. That usually starts with an assessment. Our post on the ABA assessment, CPT 97151 explains what it covers.
6. Get everything in writing. You want the approved provider, services, units, dates, and your cost sharing. A phone approval is not enough.

If the plan says no, ask for the denial in writing with the reason. You can appeal. Our guide to appealing an ABA insurance denial walks through the steps. For a state-regulated plan, you can also file a complaint with the OIC at 800-562-6900.

What to check in the agreement

Before therapy starts, make sure you know:

• Your cost sharing. It should match in network. If the plan applies your out-of-network deductible, ask why.
• Balance billing. Ask the provider to confirm in writing that they will accept the agreed rate as payment in full, apart from your normal cost share. Federal surprise billing protections cover emergencies and certain care at in-network facilities. They generally do not cover ABA you schedule with an out-of-network provider, so the agreement has to cover it.
• Which services are included. Direct therapy, BCBA supervision, parent training, and reassessments are billed under different codes. Check that each one your child’s plan needs is on the agreement.
• The end date. Agreements usually run for a set period, often lined up with a six-month authorization. Ask how renewal works and put a reminder on your calendar six weeks before it ends.

Kaiser Permanente and other narrow-network plans

Families with Kaiser Permanente Washington ask about this often. Kaiser’s ABA clinical review criteria say ABA requires preauthorization, that the plan does not cover it if your plan has no ABA benefit, and that the lead therapist or agency must be credentialed and contracted by the plan. If Kaiser’s contracted ABA providers cannot see your child in a reasonable time, call Kaiser Member Services at 1-888-901-4636 and ask how it handles network gaps for ABA under your plan.

Orchid’s in-network plans

Orchid Academy is in network with Premera Blue Cross, Regence, Blue Cross Blue Shield, Cigna, Aetna, Washington Apple Health, Molina Healthcare, Asuris Northwest Health, Personify Health, and TRICARE. If your plan is on that list, you do not need a single case agreement to start with us. Our insurance page lists what each plan usually requires.

If your plan is not on the list, tell our intake team when you request a call back. We can talk through your options and what your plan would need, and check whether an academy or in-home program near you has room. We serve families in Bellevue, Issaquah, Bothell, Sammamish, Covington, Federal Way, and East Wenatchee.