We have listed some information below based on our knowledge and experience. However, since you are ultimately responsible for payment, we highly recommend you call the number on the back of your insurance card and ask these specific questions.
Aetna - diagnosIS Code(s) strongly advised
A referral is typically only needed for HMO or Medicare Advantage plans.
We are in-network with PPO plans, but may NOT be in-network if you have an EPO plan (such as Aetna Whole Health - Puget Sound).
ICD-10 diagnosis codes from your physician (or mental health provider for ED codes) are often needed in order for us to bill Aetna. This is because most Aetna plans do not accept the generic diagnosis codes that are in our scope of practice to assign. Have your doctor fax your ICD-10 diagnosis list to us at 206-866-0204 prior to your first appointment. Alternatively, you may provide us other documentation of your assigned ICD-10 diagnosis list, such as a screenshot or download from your doctor's client portal. If we don't have codes to bill your insurance, we will have to bill you instead.
Diagnoses covered:
Preventive "Healthy Diet Counseling" is covered at no cost for people with "obesity" alone (BMI 30+), or "overweight" (BMI 25-29.9) who also have a cardiovascular risk factor (i.e. hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome).
Most other diagnoses are covered as medical and may apply to deductible/copay.
ADHD, asthma, and chronic fatigue are NOT covered.
For regular Aetna plans, all appointments are limited to 55 minutes. This is often not enough time for an initial visit so we offer the option for clients to self-pay for the additional time.
Meritain and GEHA plans allow the full 85 minutes.
Medicare Advantage Plans: These plans generally follow the same rules as straight Medicare, however some plans cover additional diagnoses. See our "Medicare" section below for more information.
BLUE CROSS BLUE SHIELD
We are considered in-network for out-of-state BCBS PPO plans, such as Anthem, BCBS of Illinois, BCBS Federal, CareFirst, and dozens more.
BCBS plans generally cover nutrition visits in full as preventive, no referral required, however there are countless different plans throughout the country and they each have their nuances.
While we ALWAYS recommend calling your insurance to check benefits for nutrition counseling, it is especially important with these plans since we are less able to catch issues.
If your plan only covers certain diagnoses, ensure your doctor sends us documentation of them so that we may use them to bill.
CIGNA - Diagnosis code(s) strongly advised
Have your doctor fax your ICD-10 diagnosis list to us at 206-866-0204. We often need this to optimize your coverage, especially if you have an eating disorder or diabetes.
At least 3 preventive visits are covered in full each year. Many plans cover additional visits but they may apply to deductible/copay/coinsurance.
Diagnoses of eating disorder or diabetes generally have no visit limit.
KAISER PERMANENTE - Referral + authorization required for HMO planS
Telehealth is covered for all plan types.
Self-funded plans and "trusts" make their own rules. VERY important to check benefits in advance for these plans.
Options PPO Plans:
Referral/ prior authorization are NOT required.
Nutrition visits are usually covered in full by Kaiser.
Core HMO Plans:
Referral/ prior authorization are always required. They authorize 6 visits initially with re-authorization required for additional visits. Authorizations expire after 6-12 months. Although we will help request additional authorizations, it is the ultimately the client's responsibility to ensure proper authorization has been obtained prior to any scheduled appointments.
If we don't have a current authorization on file, you will need to self pay at the time of service.
Nutrition visits are usually covered in full by Kaiser.
Medicare Advantage Plans: See our "Medicare" section below for additional details. We are in-network with Kaiser's standard Medicare Advantage Plan, but NOT their Anchor Med Adv Plan.
MEDICARE - Referral for dm or ckd required
MEDICARE PART B
Nutrition therapy is ONLY covered with a diagnosis of diabetes, pre-dialysis kidney disease (CKD), or 36 months post kidney transplant. Medicare does not cover pre-diabetes or any other diagnoses.
Medicare limits the amount of nutrition therapy to 3 hours for the first calendar year, whether it was provided by us, another dietitian or a combination of both. Medicare limits the amount of nutrition therapy to 2 hours for subsequent calendar years. Additional unlimited visits are covered after that when there is a change in your condition and your doctor sends us a new referral.
A referral from your Medicare doctor (MD or DO) is always required, and a new one must be obtained each calendar year. Have your doctor's office fax it to us at (206) 866-0204.
Telehealth will be covered until December 31st, 2024.
MEDICARE ADVANTAGE PLANS (a.k.a. Medicare Part C)...
These are plans offered through private insurance companies like Kaiser, Aetna, Regence etc. We bill the insurance company, not Medicare.
Medicare Advantage Plans generally have the same coverage requirements and limits as Medicare part B, but there is possibility for additional coverage, like with Kaiser.
Referrals are still required.
We are not in-network with Premera's Med Adv Plan.
We are in-network with Regence's PPO and HMO Med Adv Plans.
We are in-network with Kaiser's standard Medicare Advantage Plan, but NOT their Anchor Med Adv Plan.
MEDICARE SUPPLEMENT PLANS (a.k.a. MediGap)...
These plans don't provide any additional benefits beyond straight Medicare. If straight medicare won't cover it, a Medicare Supplement won't either. These plans only help cover copays, which don't apply to nutrition therapy.
PREMERA / LIFEWISE
No referral required for PPO plans. Referral required for all HMO plans.
Nutrition visits are almost always covered at 100%, meaning no cost to you.
EPO plans may be subject to your deductible/ copay/ coinsurance. "Individual plans" are EPO's.
Telehealth is covered same as in-person.
Self-funded plans and "trusts" make their own rules. VERY important to check benefits in advance for these plans.
PREMERA MEDICARE ADVANTAGE HMO PLANS
At this time we are not in-network with Premera's Medicare Advantage Plans.
Clients with these plans will have to self-pay at the time of service and we will not bill your insurance.
REGENCE / UNIFORM / HMA / RGA
No referral required.
PPO plans almost always cover nutrition visits in full.
Preventive visits and diagnoses of either diabetes or eating disorders are usually NOT subject to number of visit limits (i.e. 3 per lifetime). We believe all nutrition counseling is preventive and are happy to code it as such!
Telehealth is covered same as in-person.
EPO plans consider us "out of network" because we are not part of a larger organization like UW Medicine, MultiCare, Eastside Health Network, or the Everett Clinic. These plans don't cover out-of-network providers so you will have to self-pay at the time of service.
Starting 1/1/2021, we will not be in-network with the Blue High Performance Network.
Self-funded plans and "trusts" make their own rules. VERY important to check benefits in advance for these plans.
REGENCE MEDICARE ADVANTAGE PLANS (PPO and HMO)
A physician's referral with a diagnosis of diabetes or chronic kidney disease is required. Clients without a referral or covered diagnosis must self-pay at the time of service and sign a standard ABN (Advanced Beneficiary Notice of NonCoverage) form.
RATES: If you are utilizing in-network insurance to pay for services, the allowed rate is determined by your insurance company's fee schedule. After processing the claim, they will send both you and us an "Explanation of Benefits" which tells us how much (if any) of the fee is your responsibility.
If paying at the time of service and not using insurance, our rates are:
Initial Nutrition Appointment, up to 85 minutes: $250 With proof of active Medicaid enrollment: $150
Follow-Up Nutrition Counseling, up to 55 minutes: $150 With proof of active Medicaid enrollment: $100
Cut to the Chase Food Sensitivity Program (MRT+LEAP): Book a mini consult call to discuss MRT+LEAP is only available to clients enrolled in our 12 week all inclusive food sensitivity program. A portion of the program can be billed to insurance and a portion cannot. Your cost will vary depending on your insurance coverage.
No Show & Late Cancellation (<48 hours notice) Fee: $100 For late cancellations only, we will waive the fee if we are able to reschedule you for the same Mon-Fri week and you complete that appointment.
PAYMENT: A valid credit/debit card on file is required and will be used for self-pay fees, amounts insurance tells us are your responsibility (i.e. copays, deductibles, and non-covered services), and in case of late cancel or no show. You may also keep a HSA/FSA card on file for eligible transactions. Any refunds issued will be less the card processing fees we have incurred.
