Medicare Advantage Plans to cover massage therapy

Step by step…little by little…. massage therapy is being accepted by health insurance.

The latest step is the news that 270 Medicare Advantage Plans WILL be covering massage therapy.   It was a part of recent efforts by AMTA to make this happen.

Medical advantage plans are HMO or PPO plans that are approved by Medicare. There are many different types of Plans so it is not clear where the massage therapy benefits will come into play.  People purchase these plans above and beyond their Medicare coverage.

There is some concern over Medicare Advantage plans that they may be leading people away from traditional Medicare and are being dubbed Medicare Disadvantage plans.  Read more

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.

What does that mean?

We don’t really know yet and don’t have enough information.

That specific language is concerning to me… do they mean that massage therapy will only be used in home based palliative care situations and not be a part of rehabilitation benefits to reduce pain and help deal with musculoskeletal injuries?

There is much that we will need to know.  Here are some things to start asking:

• What plans will cover massage therapy?
• What is the language in each plan that says massage therapy will be covered?
• Is there a definition of medical necessity in each plan around the massage therapy benefits? What does it say?  Will massage need to be medically necessary?
• Will a prescription be required? (It will need a prescription if it needs to be medically necessary but not sure if it would if it is palliative care, but many elderly people will have many other health issues that may be a contraindication and will need to be OK’d by a doctor and maybe also prescribed by a doctor.)
• What will be covered?  Will it cover massage for rehabilitation from surgery, injuries or just the palliative care?
• Will it cover massage therapy for cancer recovery?
• What will the benefits be?
• What CPT code will be allowed?  97124 or 97140 are the two main codes allowed now by health insurance.
• How many sessions will be covered?
• How will medicare be billed?
• Will billing insurance make your massage business more profitable?  See the formula for figuring it out.

Now What?

Having Medicare recognize that massage therapy should be a part of their benefits is a good first step.  Other health insurance companies may follow once they see that Medicare approves of massage therapy.  If they are only approving it as a part of palliative care, then we have more work to do in that area.  Massage therapy could help insurance companies save money in the area of Pain Management.   AMTA at this time seems to be focusing on the pain issues and the Opioid epidemic with their recent report: Massage Therapy in Integrative Care & Pain Management

Massage therapy’s role in integrative health care has become widely accepted in major hospitals and in daily medical practice. A wealth of research has also shown the impact of massage therapy for pain management and relief.

Pain is only one very small part of what massage therapy can help with.  As a massage therapist in WA since 1989, I have been able to work with clients and bill their health insurance for many conditions such as:

• Headaches, Migraines
• Fibromyalgia
• Strains/Sprains
• Herniated Discs
• Neck, Shoulder, Back, hip, knee, foot, hand, forearm, leg pain of all sorts
• Tendinitis

Health insurance in WA does not cover massage therapy for stress, depression and anxiety which could be added to the list.

As you may already know, WA State has been billing health insurance for medically necessary massage services since about 1999 with the creation of the Every Category Law that mandates coverage by every category of provider.   It was introduced in 1993 and fought by the insurance companies until 1999 when it was upheld by a Supreme Court Decision.  (See timeline of events. )

WAC 284-170-270 Every category of health care providers.

(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-5640 and 284-43-5642 and RCW 48.43.715, for individual and small group plans; and as covered by the basic health plan, as defined in RCW 48.43.005(4), for plans other than individual and small group.

For individual and small group plans, the issuer must not exclude a category of provider who is licensed to provide services for a covered condition, and is acting within the scope of practice, unless such services would not meet the issuer’s standards pursuant to RCW 48.43.045 (1)(a). For example, if the issuer covers outpatient treatment of lower back pain as part of the essential health benefits, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope of practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(a) must not be excluded from the network.