HMO, PPO? Am I In-Network?

A dietitian recently asked us why she might be covered for nutritional counseling under a health insurance plan’s HMO (health maintenance organization) and not a particular PPO (preferred provider organization) – or vice versa. “How am I supposed to find out which plans I’m covered for under each insurance company’s offerings?” 

Why Not Fully Covered? 

There’s a reason you may not be in-network under an insurance company’s entire plan offering. You may have approached the carrier at a time when a particular network or panel was closed. The best thing to do is to call a commercial payer and ask if the network/panel is open. Request to get on all of their open panels, if possible – including commercial (HMO, PPO), community and state (Medicaid). Note that not all plans cover nutrition counseling; therefore, the insurance company will decide which plans are open and which ones will make the most sense for you to belong to as an RDN.

Some RDNs can be a part of as many as 50 different individual plans – and this may just be under one insurance company! 

Request Your Plan Coverage List

Your contract with the insurance carrier won't necessarily note which plans you're in-network with. To find out, you’ll have to call your insurance company with your request. Call the company’s contracting department and inform them which state you live in. Request the list of plans that you belong to and have it sent to you via fax or secure email. The list will contain your name, address, plan name and date you became covered under each plan.  

If you prefer not to wait on hold with the insurance company, you may also search the carrier’s online database to learn if you are a provider under a particular plan. Most companies will automatically list you as a provider in such databases – but note that some do not. 

If you have been informed that a commercial plan that you want to be a member of is closed, we suggest contacting your representative regularly to learn whether they are accepting any new RDNs. You may also submit an appeal if the plan is an attractive one for you. Or, you can have your Healthy Bytes team member assist you with all of the above

What questions do you have about plan coverage?