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Is Your Child’s Treatment Covered? Exploring SCAs, In-Network, and PPO Insurance Options

Insurance is an important option to explore when paying for treatment for your preteen, teen, or young adult child. This blog will discuss the three types of insurance coverage represented in the insurance filter. Because insurance varies widely, it is crucial that you, the consumer, call your insurance company and verify your benefits before enrolling your child in any level of treatment.  To be more specific, verify that your chosen provider covers the required type of treatment.  An example is if a diagnosis requires mental health treatment, call and confirm and document that the provider is covering or in-network for mental health and not another diagnosis.  

1. Single Case Agreements (SCAs)

  • SCAs are negotiated agreements between an individual healthcare provider and an insurance company for specific cases or patients.
  • These agreements are made when in-network providers cannot adequately meet the patient’s needs or when the patient wants to see a specific out-of-network provider.
  • SCAs are typically used for specialized treatments or circumstances where the patient’s needs cannot be met within the insurance network.
  • The terms of SCAs, including reimbursement rates and treatment duration, are negotiated on a case-by-case basis.

2. In Network:

    • In-network providers have negotiated contracts with the insurance company, agreeing to provide services at discounted rates to plan members.
    • Patients typically pay lower out-of-pocket costs when they visit in-network providers.
    • Insurance plans often have a directory of in-network providers, and patients are encouraged to choose healthcare providers from this list to maximize coverage and minimize costs.
    • Providers must meet certain quality and credentialing standards to become in-network.
    • Any level of treatment could be In-network with one or many treatment providers.

    3. Preferred Provider Organization (PPO):

    • PPO plans offer a network of healthcare providers but also cover out-of-network care, albeit at a higher cost to the patient.
    • Patients can see any healthcare provider they choose, whether in-network or out-of-network, without needing a referral from a primary care physician.
    • Out-of-pocket costs for services received from out-of-network providers are typically higher than those for in-network providers but still lower than if the patient had no insurance at all.
    • PPO plans often have higher premiums than HMO (Health Maintenance Organization) plans but offer greater flexibility in provider choice. (HMOs could have in-network providers that are listed in this directory, too.)  

    If you hope to use insurance to cover treatment, CALL YOUR INSURANCE PROVIDER TO VERIFY YOUR BENEFITS.  Do not assume something you are reading on this or a provider’s website.   

    In summary, while in-network and PPO arrangements involve broader networks of providers with pre-established agreements, SCAs are agreements negotiated on a case-by-case basis between individual providers and insurance companies to cover particular patients or treatments not readily available within the existing network.

    Read these blogs to learn more about insurance or alternative funding sources:

    Insurance Billing: the 101 Course

    5 Questions You Must Ask to Verify Mental Health Insurance

    Navigating the Costs and Insurance Aspects of IOP Programs: A Comprehensive Guide

    Can Your School System Help With Treatment Options? 8 Questions To Ask