Guide

Pricing an RD practice when the competitor down the road is a $0 copay

Summary

The free nutrition visit a cash-pay dietitian competes with is narrower than it looks, so price against the gap it leaves. Federal law waives cost sharing for preventive services the U.S. Preventive Services Task Force grades A or B, and the two nutrition-related ones are population-scoped: adults with cardiovascular risk factors, and adults with a BMI of 30 or higher. The waiver also stops at the network line. Outside those bounds, a free visit is a plan's own choice, not a federal requirement.

By Gale Editorial · Updated 2026-09-02. Every figure cited to a dated source. How we write.

Where the $0 nutrition visit comes from

From a single federal cost-sharing rule. A non-grandfathered group health plan or issuer has to cover any item or service the U.S. Preventive Services Task Force rates A or B with no copayment, no coinsurance and no deductible 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.. Nutrition counseling reaches that list through two Grade B recommendations, which is why a patient can walk into a covered visit and be charged nothing at all.

The requirement is written for non-grandfathered plans 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service., so an older plan that has kept its grandfathered status is not carrying it. That is a fact about the patient in front of you, and the plan document is the thing that answers it.

Somebody is being paid for the free visit. The rule governs what a plan may pass along to the patient 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service., and the zero on the patient's side of the counter says nothing about what the visit costs to deliver.

Who the free visit is for

Two named populations, both narrower than the reputation of the benefit. The Task Force's 2020 statement is graded B and covers adults who already have cardiovascular risk factors, and its verb is offer or refer 2Ref 2U.S. Preventive Services Task Force (2020).Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions.That the 2020 diet and physical activity counseling recommendation is Grade B, scoped to adults with cardiovascular risk factors, and worded as offer or refer.. The 2018 weight-loss statement is graded B as well and reaches adults with a BMI of 30 or higher 3Ref 3U.S. Preventive Services Task Force (2018).Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions.That the second relevant Grade B recommendation, from 2018, reaches only adults with a BMI of 30 or higher, which bounds the size of the free-visit population.. A patient outside both descriptions is outside the mandate.

So the free visit has edges, and the edges are written down. The person with reflux, the athlete rebuilding an eating plan, the parent of a child who eats four foods, the person managing a new food allergy: none of those descriptions appears in either recommendation. Both statements are also worded as offer or refer, which leaves a referring clinician in the middle of whether the benefit gets used at all 2Ref 2U.S. Preventive Services Task Force (2020).Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions.That the 2020 diet and physical activity counseling recommendation is Grade B, scoped to adults with cardiovascular risk factors, and worded as offer or refer.3Ref 3U.S. Preventive Services Task Force (2018).Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions.That the second relevant Grade B recommendation, from 2018, reaches only adults with a BMI of 30 or higher, which bounds the size of the free-visit population..

But a federal minimum is a floor, and a plan may cover more than the floor requires.

That is a per-plan question with a per-plan answer. Reading the patient's own plan documents before quoting a price costs a few minutes and settles it for that patient.

The network line is where the price comes back

The waiver follows the network, so the zero disappears the moment the visit is out of network. The same rule that bars cost sharing on an A or B rated service says the bar does not apply when a non-participating provider delivers it 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.. A cash practice that never signs a plan contract is not competing with zero. It is competing with whatever that plan's out-of-network terms cost the patient.

That changes what the practice is compared against. A patient weighing an out-of-network dietitian is holding a fee up against their own out-of-network exposure and against the wait for an in-network appointment. A common convention is to hand the patient an itemized receipt to file themselves, and whether their plan pays anything against it is a question about that patient's benefit.

Staying out of network changes more than the rate. Whether the practice is still a HIPAA covered entity turns on the covered-entity test, and that is worth settling before the first patient rather than after it, because the answer decides what paperwork the practice keeps from the first week.

Can you take cash from a Medicare patient?

Only under conditions the regulations spell out, and a dietitian is named in them by title. Medicare's covered nutrition benefit is medical nutrition therapy, defined for managing diabetes or a renal disease, including the window after a transplant, and it must be furnished by a registered dietitian or nutrition professional 4Ref 4Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Definitions.That Medicare's covered dietitian benefit, medical nutrition therapy, is defined for managing diabetes or a renal disease and must be furnished by a registered dietitian or nutrition professional.. A service outside that definition is outside the covered benefit, which is where a good deal of cash nutrition work already sits.

The covered benefit also runs out. Medicare caps the covered hours in a year and allows more only when a physician documents a change in diagnosis, medical condition or treatment regimen related to the diabetes or renal disease 5Ref 5Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Medical nutrition therapy.That the MNT benefit is hour-capped each year and that additional hours require a physician-documented change in diagnosis, medical condition or treatment regimen; the section does not state the hour figure itself.. The regulation that sets the cap does not print the number of hours. That figure lives in CMS's separate coverage guidance, so pull it from CMS and date it rather than carrying a number over from a summary.

For a service Medicare does cover, taking cash instead is a formal act with paperwork. Title 42 names registered dietitian or nutrition professional among the practitioner types who may sign private contracts with beneficiaries and file an affidavit opting out, and the resulting opt-out period runs two years 6Ref 6Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (1998).Definitions.That registered dietitian or nutrition professional is a named practitioner type eligible to sign private contracts and opt out of Medicare, and that the opt-out period runs two years..

But opting out is all or nothing for that whole period. Once the affidavit is filed, the dietitian may not furnish any item or service that would otherwise be covered by Medicare to any Medicare beneficiary except through a private contract 7Ref 7Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (1998).Effects of opting-out of Medicare.That opting out is all-or-nothing for the whole opt-out period: no Medicare-covered item or service may be furnished to any beneficiary except through a private contract.. It is a decision about the entire practice, taken with counsel and with a real count of how many Medicare patients the practice sees.

Setting the number

Start from what the practice costs to run and what one episode of care contains, then check the result against the gap the free visit leaves. Overhead and billable hours give the price floor, and the arithmetic sits on its own page along with the startup budget behind it. The competitor's zero belongs in how the practice describes itself to a patient. It does no work in the arithmetic.

Price a defined episode where the work genuinely is an episode. A common convention in cash practice is a first visit plus a set number of follow-ups across a stated window, with the contents written down: what gets assessed, what the goals are, how often the patient is seen and for how long. Pricing cash-based physical therapy runs on the same structure, for the same reason. An episode gives a patient something to compare against a single covered visit.

A cash-only launch also skips payer credentialing, which is the longest lead time in most launch plans and the reason the 12-month runway looks different for a practice that never files a claim.

Four situations a cash rate has to survive:

Patient situation	What the rule says	What is left to price
Non-grandfathered plan, A or B rated preventive service, in network	No copayment, coinsurance or deductible on that service 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.	Your network contract governs
The same service, delivered out of network	The no-cost-sharing requirement does not apply 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.	Your fee, against the patient's out-of-network exposure
Medicare beneficiary, diabetes or renal disease	Medical nutrition therapy is covered and hour-capped each year 4Ref 4Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Definitions.That Medicare's covered dietitian benefit, medical nutrition therapy, is defined for managing diabetes or a renal disease and must be furnished by a registered dietitian or nutrition professional.5Ref 5Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Medical nutrition therapy.That the MNT benefit is hour-capped each year and that additional hours require a physician-documented change in diagnosis, medical condition or treatment regimen; the section does not state the hour figure itself.	Hours past the annual cap sit outside the covered benefit unless a physician documents a qualifying change 5Ref 5Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Medical nutrition therapy.That the MNT benefit is hour-capped each year and that additional hours require a physician-documented change in diagnosis, medical condition or treatment regimen; the section does not state the hour figure itself.; confirm the billing route before quoting one
Medicare beneficiary, outside diabetes or renal disease	Outside the covered benefit's definition 4Ref 4Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001).Definitions.That Medicare's covered dietitian benefit, medical nutrition therapy, is defined for managing diabetes or a renal disease and must be furnished by a registered dietitian or nutrition professional.	Your fee, once you have established which side of that definition the visit sits on 7Ref 7Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (1998).Effects of opting-out of Medicare.That opting out is all-or-nothing for the whole opt-out period: no Medicare-covered item or service may be furnished to any beneficiary except through a private contract.

What to say when a patient asks why it is not free

Answer with what is true for that patient: which populations the free benefit names, and whether the practice is in their network. Both are checkable while they are sitting there, and neither answer requires a word about the quality of the covered visit. The comparison a patient can make is between a defined episode of care with a named practitioner and a benefit their plan may or may not owe them.

Three checks carry that conversation:

Whether their plan is non-grandfathered, which decides whether the preventive rule reaches them at all 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.
Whether they fit either population the two recommendations name, cardiovascular risk factors or a BMI of 30 or higher 2Ref 2U.S. Preventive Services Task Force (2020).Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions.That the 2020 diet and physical activity counseling recommendation is Grade B, scoped to adults with cardiovascular risk factors, and worded as offer or refer.3Ref 3U.S. Preventive Services Task Force (2018).Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions.That the second relevant Grade B recommendation, from 2018, reaches only adults with a BMI of 30 or higher, which bounds the size of the free-visit population.
Whether the practice participates in their network, which is the line where the zero stops 1Ref 1U.S. Department of Health and Human Services (2010).Coverage of preventive health services.The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.

Write the answer down once, in the intake material, so those checks happen before a first visit instead of during one.

Common questions

If the practice is out of network, the federal no-cost-sharing requirement does not reach that visit and the patient is on their plan's out-of-network terms. If the practice participates in the plan, the network contract governs what may be collected, and that contract is the document to read before quoting anything. The patient's plan status decides the answer, so check it before the first visit.

Two Grade B recommendations reach nutrition counseling: a 2020 statement on diet and physical activity for adults with cardiovascular risk factors, and a 2018 statement on behavioral weight-loss interventions for adults with a BMI of 30 or higher. Both are worded as offer or refer. A plan may cover more than the federal floor requires, so the plan documents are the only way to know for one patient.

Yes. Registered dietitian or nutrition professional is one of the practitioner types named in Medicare's private-contract rules, and the opt-out period runs two years. It is not a patient-by-patient choice: after the affidavit is filed, every service that Medicare would otherwise cover, for every Medicare beneficiary, has to run through a signed private contract for the whole period.

The regulation caps the hours per year without printing the number, and it allows more only when a physician documents a change in diagnosis, medical condition or treatment regimen related to the diabetes or renal disease. The figure itself sits in CMS coverage guidance rather than in the regulation, so take it from CMS directly and record the date you took it.

That is a positioning question, and the arithmetic runs the other way around. Overhead, billable hours and the contents of one episode set the floor; the free visit sets the story told about the price. If the floor lands above what patients will pay for a single visit, the usual move is to change what the price buys.

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References

1.U.S. Department of Health and Human Services (2010). Coverage of preventive health services. Electronic Code of Federal Regulations (eCFR), Title 45, Part 147, § 147.130. link ✓The federal no-cost-sharing requirement for USPSTF A/B rated preventive services on non-grandfathered plans, and the fact that the requirement does not apply when a non-participating provider delivers the service.
2.U.S. Preventive Services Task Force (2020). Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions. U.S. Preventive Services Task Force, Recommendation Statement. link ✓That the 2020 diet and physical activity counseling recommendation is Grade B, scoped to adults with cardiovascular risk factors, and worded as offer or refer.
3.U.S. Preventive Services Task Force (2018). Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions. U.S. Preventive Services Task Force, Recommendation Statement. link ✓That the second relevant Grade B recommendation, from 2018, reaches only adults with a BMI of 30 or higher, which bounds the size of the free-visit population.
4.Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001). Definitions. Electronic Code of Federal Regulations (eCFR), Title 42, Part 410, Subpart B, § 410.130. link ✓That Medicare's covered dietitian benefit, medical nutrition therapy, is defined for managing diabetes or a renal disease and must be furnished by a registered dietitian or nutrition professional.
5.Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (2001). Medical nutrition therapy. Electronic Code of Federal Regulations (eCFR), Title 42, Part 410, Subpart B, § 410.132. link ✓That the MNT benefit is hour-capped each year and that additional hours require a physician-documented change in diagnosis, medical condition or treatment regimen; the section does not state the hour figure itself.
6.Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (1998). Definitions. Electronic Code of Federal Regulations (eCFR), Title 42, Part 405, Subpart D, § 405.400. link ✓That registered dietitian or nutrition professional is a named practitioner type eligible to sign private contracts and opt out of Medicare, and that the opt-out period runs two years.
7.Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (1998). Effects of opting-out of Medicare. Electronic Code of Federal Regulations (eCFR), Title 42, Part 405, Subpart D, § 405.425. link ✓That opting out is all-or-nothing for the whole opt-out period: no Medicare-covered item or service may be furnished to any beneficiary except through a private contract.

https://www.gale.care/for-providers/se-dietitian-cash-vs-covered-visits · 7 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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