The Reality of Single Case Agreements in 2026: What's Working and What's Not

Single case agreements — the mechanism allowing out-of-network providers to deliver services at negotiated in-network rates for specific clients — are facing heightened scrutiny from managed care organizations nationwide. In Georgia, two major Medicaid managed care plans dominate the conversation: one regional MCO which covers approximately 25% of the state's Medicaid population, and another regional MCO which has been gaining market share as other plans exit the state.

Both payers have tightened SCA approval criteria significantly over the past 12 months, with approval rates dropping from historical norms of 60-70% to current levels closer to 30-40%. The shift coincides with broader industry consolidation, as one regional MCO recently announced 20% rate cuts for in-network ABA providers, signaling increased cost containment pressure across all payment mechanisms.

The Near-Term Impact

Providers are spending 40-60% more administrative time per SCA application with lower success rates, creating negative ROI on pursuit efforts for all but the highest-value cases. This forces immediate decisions about which families to serve and whether to invest in lengthy credentialing processes with plans that may not offer sustainable long-term rates.

The Broader Context

The SCA squeeze reflects payers' broader strategy to control network composition and utilization patterns rather than simply negotiate individual cases. As state Medicaid programs face budget pressure and managed care organizations consolidate, the path of least resistance is eliminating exceptions rather than managing them case-by-case — a trend we're seeing replicated in Texas, Florida, and North Carolina markets.

Multiple operators are reporting similar patterns across the Southeast region. One Georgia provider noted:

The documentation requirements have also intensified significantly. As another operator explained:

Several providers are questioning whether the administrative investment makes financial sense. A multi-state operator observed that they're tracking about 8-10 hours of admin time per SCA application — between the initial submission, follow-ups, and appeals. At typical billing rates, that requires at least 15-20 hours of approved service delivery just to break even on the admin cost.

The SCA market is bifurcating into high-value exceptions and administrative waste. Payers are using procedural complexity as a de facto rationing mechanism, knowing that most providers will abandon pursuit rather than invest in lengthy appeals processes.

This isn't necessarily bad policy — it forces providers to make strategic choices about network participation rather than operating permanently on the margins. Smart operators should treat SCAs as a last resort for truly exceptional cases rather than a substitute for network development.