Picture an employee who sees a therapist every Tuesday morning. She has been with the same clinician for two years, and the anxiety that once cost her three sick days a month is finally steady. Now picture your renewal. You found a plan that saves the company real money, the census looks clean, and you sign. Three weeks later she is at the HR desk, upset. Her therapist is out of network on the new plan. The next in-network opening is months out. She is already rationing the sessions that kept her working.

This is the part of a carrier switch that never shows up on the comparison spreadsheet. That spreadsheet lines up premiums, network size, and deductibles. It does not flag the pregnant employee in her second trimester, the man three infusions into a cancer protocol, or the dozen people quietly holding steady in weekly therapy because the treatment works. When the plan changes, their care can change with it. The people who feel it first are usually the ones who can least afford the disruption.

There is a federal protection built for exactly this moment. Most employers assume it covers anyone in the middle of treatment. It does not. The gap between what the law guarantees and who is actually in care is wide, and it falls hardest on routine mental-health treatment. Closing that gap takes a specific tool many HR teams have never had to use. Here is the full picture, with the numbers behind it.

Key Takeaways
  • The federal No Surprises Act guarantees up to 90 days of continued care only for five narrow categories, not for most people in ongoing treatment.
  • Routine outpatient therapy usually falls outside that guarantee, even though it is the most common form of active care in a typical group.
  • A single case agreement keeps one out-of-network provider paid at close to in-network terms for one patient.
  • Map who is mid-treatment before you sign, and build the continuity plan into the switch instead of reacting to it after.

How many of your people are actually mid-treatment right now

Start with scale, because the scale is what surprises people. The 2023 National Survey on Drug Use and Health, the annual study SAMHSA runs, found that 23.0% of US adults, about 59.2 million people, received some form of mental health treatment in the past year. That is nearly one in four adults, counting therapy, medication, or both.

The same survey put the share of adults with any mental illness at 22.8% in 2023, roughly 58.7 million people. Of that group, about 54% actually received services, which means close to half went untreated. At the acute end, 14.6 million adults had a serious mental illness, and about 71% of them got treatment. These are not fringe numbers. They describe a normal cross-section of any workforce.

Now run the rate against a real group. A company with 100 employees usually covers more than 200 lives once spouses and children enroll. Apply the national 23% figure and roughly 45 of those covered people touched mental health treatment in the past year. Treat that as illustrative. It applies a national average to one sample group, and your real count depends on your demographics, your plan design, and how many dependents sign up. The point is the order of magnitude. It is not two or three people. It is dozens, and some share of them are in active, week-to-week care on the day you change carriers.

Mental health is only one slice. Layer in the pregnancies, the chronic conditions managed by one specific specialist, the post-surgical follow-ups, and the cancer and autoimmune protocols, and the mid-treatment population in a mid-size group is a meaningful fraction of the whole. Every one of them has a provider relationship that a network change can sever. If you want a read on how exposed your group is before you shop, our guide to network adequacy for mid-market employers walks through how to spot the gaps that matter.

What the federal 90-day rule actually promises

Congress wrote a continuity-of-care right into the No Surprises Act, which passed as part of the Consolidated Appropriations Act, 2021. CMS and the Department of Labor enforce it, and it applies to plan years beginning on or after January 1, 2022. The mechanism is straightforward. When an in-network provider or facility becomes out-of-network, the plan has to offer certain patients the option to keep seeing that provider under the same terms and the same cost-sharing for up to 90 days. CMS lays out the details in its overview of key No Surprises Act consumer protections.

Same cost-sharing is the phrase that carries the weight. For that window, the patient keeps paying in-network copays and coinsurance even though the provider has left the network. The plan cannot quietly reprice the visits at the out-of-network rate and call it continuity.

Three things trigger the right. The contract between the plan and the provider ends. The provider's participation terms change so the provider is no longer in-network. Or the contract between the plan and the insurer ends and benefits under it are lost. One case is carved out. If a provider is dropped for cause, meaning for reasons such as a quality problem or fraud, the protection does not apply. The law will not force a plan to keep paying a provider it removed for misconduct.

The window is not open-ended. It ends at the earlier of two points: 90 days from the notice of termination, or the date the person is no longer a continuing care patient. That second phrase is where the whole thing turns, because continuing care patient has a narrow legal definition. Only five situations qualify a person:

Read that list against your mid-treatment population and the problem comes into focus.

The people that rule quietly leaves out

The five categories are real, and for the people who fit them they matter. A pregnant employee keeps her obstetrician through delivery. Someone partway through a cancer protocol keeps the oncologist. An inpatient is not forced to switch facilities in the middle of a stay. That is worth telling employees who qualify, because the protection is genuine and they should use it.

The trouble is everyone the list skips. Routine outpatient care is not on it. The most common form of ongoing treatment in your group, weekly or biweekly outpatient therapy, generally does not qualify unless it rises to the level of a serious and complex condition. Stable, effective therapy for anxiety or depression usually does not clear that bar precisely because it is working. The person is functioning, holding a job, managing symptoms. Nothing about their week reads as life-threatening or disabling. So the federal 90-day guarantee, the one most employers assume has them covered, does not reach them.

Go back to the illustrative 45 people in mental health treatment. A handful might qualify through a serious and complex diagnosis. The large majority, the ones in routine outpatient care, fall into the gap. They have no automatic right to keep their provider at in-network cost after a switch. Their choices shrink to paying the out-of-network rate, often the provider's full cash charge, or starting over with someone new and hoping the next opening is not months away. Continuity of the therapeutic relationship, which is a real part of why treatment works, is not something the federal floor protects for them.

This gap sits next to an obligation employers already carry. Federal parity law requires that mental health benefits be no more restrictive than medical and surgical benefits, and network access is part of that analysis. Our overview of mental health parity compliance covers where network decisions and parity intersect. A switch that strands therapy patients is not only a morale problem. It can raise parity questions too.

How a single case agreement closes the gap

The tool that fills the gap is the single case agreement, sometimes shortened to SCA. It is a temporary, patient-specific contract between an out-of-network provider and the plan, covering one patient and one episode of care. It is not a network contract. It does not add the provider to the network for anyone else. It simply lets this one person keep this one provider on terms both sides accept.

The economics usually land in a predictable place. The negotiated rate tends to fall between the plan's in-network rate and the provider's usual out-of-network charge. It can be structured a few ways: a per-diem for facility care, a percentage of usual and customary charges, or a flat case rate for a defined course of treatment. For a therapy patient, that often means the plan agrees to pay the provider close to an in-network rate so the patient's out-of-pocket cost stays roughly what it was.

These agreements are typically bounded. An SCA might cover a set number of sessions or a fixed window rather than open-ended care. When treatment needs to continue past that point, the agreement is usually renewable with updated clinical notes that show the care is still medically necessary. That renewal step is normal, not a denial.

Single case agreements come into play when three things line up: the care is medically necessary, the provider is out-of-network, and there is no suitable in-network alternative available within a reasonable time or distance. That last condition is where documentation earns its keep. When you can show that the in-network options are full, too far, or unable to take the patient for weeks, the request gets much stronger. Documented network inadequacy is the argument that moves it from a favor to a reasonable accommodation. This is a routine part of how out-of-network billing is handled, so providers and plan administrators know the process even when your employees do not. For groups where mental health access is a recurring pressure point, our piece on mental health coverage and network continuity goes deeper on keeping therapy access intact through a plan change.

Where state law adds protection, and where it stops short

The federal rule is a floor, not a ceiling. States can add their own continuity-of-care and balance-billing protections on top, and many have. Roughly 33 states have some form of balance-billing or continuity statute on the books. The catch is that they vary enormously. Some reach further than the federal categories and cover more situations. Some are narrower, apply only to state-regulated plans, or carve out the same routine outpatient care the federal rule skips.

Two structural limits matter for employers. First, most self-funded employer plans are governed by ERISA, which generally preempts state insurance mandates, so a strong state continuity law may not apply to a self-funded group at all. Second, even in states with real protections, routine therapy is frequently outside what the statute covers. So the state-law backstop is genuine in some places and mostly absent in others, and you cannot assume it fills the gap the federal rule leaves.

The practical move is to check your specific state and your specific plan type rather than assume either direction. Where a state law is stronger than the federal floor and it applies to your plan, use it. Where it does not reach, the single case agreement is what you have.

A switching playbook that protects people in treatment

None of this means you should avoid switching carriers. A better plan is a better plan, and sometimes the move is right. It means you switch with the mid-treatment population in view instead of discovering them at the HR desk in week three. Here is the sequence that keeps people covered.

  1. Map who is mid-treatment before you sign. Use the outgoing plan's continuity-of-care notice obligations along with your own benefits census to identify who is in active care. You will not get diagnoses, and you should not try to, but you can communicate early and invite employees to raise a continuity concern in confidence. The goal is to know the shape of the exposure before the effective date, not after.
  2. Sort your people into protected and gap. Work out who lands in the five federal categories and gets the automatic 90 days, and who falls into the gap, especially the routine therapy population. The two groups need different handling, and knowing which is which up front tells you where to spend effort.
  3. Build single case agreement requests into the transition timeline. For the gap population, start gathering clinical documentation early and line up the SCA requests so they are ready at or before the switch. Waiting until a patient hits an out-of-network bill means weeks of stress and possibly missed sessions. Prepared requests move faster.
  4. Time the switch to your renewal and protect deductible credit. Where you can, align the change with the renewal date and carry over accumulated deductible and out-of-pocket credit so people mid-year are not reset to zero. Our guide to deductible credit on a mid-year switch covers how to preserve it.
  5. Stack any stronger state law on top of the federal floor. If your state has a continuity statute that reaches further and applies to your plan type, use it for the people it covers, and fall back to single case agreements for everyone it does not.
  6. Check network overlap before you sign, not after. The cleanest way to protect continuity is to lose fewer providers in the first place. Compare the incumbent and incoming networks for the specialists and clinicians your people actually use. Fewer dropped providers means fewer gap cases to manage. Our network adequacy guide shows how to run that overlap check.

Do these six things and a carrier switch stops being a quiet threat to the people in your group who are getting better. The savings are still real. The difference is that nobody in active treatment pays for them with their care.

Frequently Asked Questions

Can I keep my therapist if my employer changes insurance?

Sometimes automatically, often not. The federal No Surprises Act guarantees up to 90 days with a provider who leaves the network only for five narrow situations, and routine outpatient therapy usually is not one of them. If your care does not fit those categories, the practical path is a single case agreement, a one-patient contract that keeps your therapist paid at close to in-network terms while you continue care or transition.

Does the 90-day continuity rule cover mental health therapy?

Only when the therapy treats a serious and complex condition as the No Surprises Act defines it. Stable, effective outpatient therapy for anxiety or depression generally does not meet that bar, so it falls outside the automatic 90-day guarantee. That is the gap most employers do not expect, since mental health treatment is the most common form of ongoing care in a typical group.

What is a single case agreement and who requests it?

A single case agreement is a temporary contract between an out-of-network provider and the health plan that covers one patient and one course of care. The provider's billing office usually starts it, often with the patient or the employer's benefits team pushing it forward. The negotiated rate typically sits between the plan's in-network rate and the provider's usual charge, and documented lack of an in-network alternative strengthens the request.

How long do I have to move to a new in-network provider?

If you qualify for federal continuity of care, the protected window runs up to 90 days from the termination notice, or until you are no longer a continuing care patient, whichever comes first. If you do not qualify, there is no federal clock, but a single case agreement can bridge the time you need to either continue with your current provider or find an in-network one who can take you.

Does switching carriers reset my deductible?

It can, unless the employer arranges deductible credit carryover. Many mid-year switches let accumulated deductible and out-of-pocket amounts transfer so employees are not reset to zero, but this has to be set up during the transition. Confirm it before the switch rather than assuming it happens automatically.

What counts as a serious and complex condition under the No Surprises Act?

For an acute condition, one serious enough that specialized treatment is needed to avoid death or disability. For a chronic condition, one that is life-threatening, degenerative, or disabling and requires ongoing specialized care. CMS describes these protections in its overview of the No Surprises Act at cms.gov. Conditions that fit this definition qualify for the 90-day continuity window, while routine, stable conditions generally do not.