Your plan covers ABA, but every in-network provider you call is full, does not serve your area, or cannot meet a specific need, such as therapy in your family's language. Paying out-of-network rates for many hours a week is out of reach for most families. This is where a network exception or a single case agreement can help. This guide explains what they are, when plans tend to grant them, what Florida and federal rules say, and how to build your request.
This is general information. Your plan's documents and its member-services team decide how your plan handles these requests.
What is a single case agreement, and how is it different from a network exception?
The names vary from plan to plan, but the ideas are similar:
- A network exception (sometimes called a gap exception or network adequacy exception) is the plan agreeing to treat an out-of-network provider's services as if they were in-network for your cost sharing, because the network cannot meet the need.
- A single case agreement is a contract between the plan and one out-of-network provider for one patient. It usually sets the rate the plan will pay, the services and dates covered and whether the provider may bill you more than your cost share.
Often the two go together: the plan grants an exception, then signs a single case agreement with the provider. Either way, the provider must agree too. A plan cannot force a provider into an agreement, and a provider can decline.
| In-network provider | Out-of-network with an approved exception or agreement | Out-of-network, no agreement | |
|---|---|---|---|
| Your cost share | In-network deductible, copay or coinsurance | Often in-network level, if the agreement says so | Out-of-network level, if the plan has out-of-network benefits at all |
| Can the provider bill you the difference? | No, beyond your cost share | Depends on the agreement; ask for it in writing | Yes, in many plans |
| Prior authorization | Required by most plans | Usually still required | Usually still required |
| Who files claims | The provider | The provider | Sometimes you |
For Florida PPO policies, the law requires this warning in the policy: "Nonparticipating providers may bill insureds for any difference in the amount" (Fla. Stat. 627.6471(7)). That is why the agreement's billing terms matter. More in in-network vs out-of-network ABA.
When does a request make sense?
Plans usually look for a gap the network cannot fill. Common situations:
- No availability: in-network providers are not accepting new clients, or cannot start for a long time.
- No coverage in your area or setting: no in-network provider serves your county, or none can provide services in the setting the treatment plan calls for (home, school, daycare or community).
- A specific clinical need: for example, a provider who speaks your child's home language, or experience with a co-occurring condition, documented by your child's doctor.
- Continuity of care: your child is mid-treatment with a provider who left the network, or you changed plans.
Requests based only on preference ("we like this provider better") are rarely approved.
What do Florida and federal rules say?
No Florida statute uses the phrase "single case agreement." But several rules support a request, depending on your plan type:
- Florida HMOs: each HMO "shall develop and maintain a policy to determine when exceptional referrals to out-of-network specially qualified providers should be provided to address the unique medical needs of a subscriber" (Fla. Stat. 641.51(6)). Ask your HMO for that policy.
- Florida PPO and EPO policies: if a covered service "is not within the scope of services provided by the network," the law says it "shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to preferred providers" (627.6471(4)(h); the EPO version is 627.6472(9)). Whether this applies to your situation is for the insurer and, in a dispute, the Florida Department of Financial Services to decide.
- Accurate directories: Florida PPO insurers must post a list of preferred providers on their website and update it at least monthly (627.6471(2)). If listed providers are not actually available, write that down.
- Self-funded employer plans: Florida's insurance rules generally do not reach them, but federal parity law does for employers with more than 50 employees. In Field Assistance Bulletin 2026-03 (September 2026), the U.S. Department of Labor said that where there are network adequacy parity issues it will ensure plans "consider all available options" to help members get covered mental health treatment "without exposing such participants and beneficiaries to out-of-network costs." The bulletin does not mention ABA by name.
For contrast: Florida Medicaid managed care plans, which began paying for behavior analysis in February 2025, were required to offer a continuity-of-care period in which out-of-network providers could still be paid. That is a Medicaid rule. Commercial plans have no equivalent blanket rule for ABA, which is why the evidence you gather matters.
What evidence shows there is no available in-network provider?
Build a simple log. It is the heart of your request.
- Start from the plan's own directory. Search for ABA providers in your area, and save or print the results with the date.
- Call each provider. Record the date, the provider's name, who you spoke with and the answer: not taking new clients, cannot start until a given date, does not serve your area, does not offer the needed setting or language, or no longer in network.
- Ask the plan for help first. Call member services and ask it to find an in-network ABA provider who can start. Note the reference number and what it offered. Plans often ask whether you tried this.
- Get clinical support. Ask your child's doctor for a short letter of medical necessity explaining the need and, if it applies, why timing or a specific skill matters.
- Find the out-of-network provider. Confirm it can serve your child and is willing to enter an agreement with your plan.
Our insurance call script has a notes sheet you can use for the log.
How do I make the request?
- Call member services and ask: "How do I request a network exception or single case agreement for ABA?" Ask for a case manager if one is available.
- Submit in writing following the plan's instructions: your log, the directory printouts, the doctor's letter, the diagnosis and the out-of-network provider's details.
- Let the provider and plan negotiate. The rate is between them. The provider may also need to submit the treatment plan for prior authorization.
- Get the approval in writing. Check the dates covered, the services and units, your cost share and whether the provider may bill you beyond it. Note the end date so you can ask for an extension before it runs out.
- If the plan says no, ask for a written denial with the reason and the criteria used. A denial of a network exception can often be appealed like other benefit decisions. See how to appeal an ABA denial. For fully insured plans you can also call the DFS Insurance Consumer Helpline at 1-877-693-5236; for self-funded plans, EBSA at 1-866-444-3272.
Can Hope Center work with my plan through an agreement?
Hope Center works in network with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR, Personify Health and TRICARE East. Optum is onboarding and not yet in network. If your plan is not one of these, call us before you file a request: we will tell you honestly whether we can take part, and if not, explain other options such as self-pay with a sliding scale. We have no waitlist, which can matter when an in-network search has stalled. See insurance at Hope Center, contact us or call 561-337-8865.