If you or a loved one are covered by MassHealth and have sought treatment from a provider outside of your network, you may have encountered a single case agreement (SCA). An SCA is an agreement between MassHealth and a provider that allows for a patient to receive treatment from that provider despite not being in-network.

It is important to note that SCAs are typically only granted in cases where the patient has a specific health need that cannot be met within the MassHealth network. Patients must also show that they have attempted to find an in-network provider but have been unable to do so.

To initiate an SCA, the patient`s healthcare provider must submit a request to MassHealth along with supporting documentation, such as medical records and a treatment plan. MassHealth will review the request and make a determination on whether to grant the agreement.

It is also important to note that SCAs are typically temporary and only cover a specific course of treatment. Once the treatment is complete, the patient will need to return to their in-network provider for ongoing care.

SCAs can be beneficial for patients who require specialized or unique treatment that is not readily available within the MassHealth network. However, it is important to carefully consider the potential financial implications of receiving treatment outside of your network. Patients may be responsible for additional out-of-pocket costs, and MassHealth may not cover all of the costs associated with an SCA.

In conclusion, if you are considering seeking treatment from a provider outside of your MassHealth network, it is important to understand the single case agreement process and potential financial implications. Consulting with your healthcare provider and MassHealth can help you make an informed decision about your care.