Using your health insurance for massage therapy is more confusing than it should be. I spend a lot of time helping people navigate this world, even though I’m no longer “in-network” with any plans. Between my experience billing as a provider and my previous career with State Farm Insurance, I became familiar with the terminology and process.
So let’s break down some of the most common terms you hear with health insurance and massage therapy.
The most important thing to know is that in order for massage therapy to be covered by your health insurance, it needs to be medically necessary. Health insurance rarely covers massage for wellness or relaxation (at least I’ve never seen a plan that does.) Though your insurance plan ultimately decides what is medically necessary, having a prescription with a diagnosis from your primary care doctor shows medical necessity and is required by massage therapists to bill your insurance.
Prescription vs. Referral
One of the most confusing things about insurance is when these terms are used interchangeably. They are in fact, two different things! Your health plan may tell you that you don't need a referral for massage, which only means that you can self-refer, or choose your own provider for massage therapy. A referral comes from your primary care physician who sends you to a specific in-network provider. A prescription, however, can come from your primary doctor, naturopath, chiropractor or any doctor who has authority to diagnose and prescribe. It includes the diagnoses codes, frequency and duration of treatment. The prescription can be taken to any massage therapist and we need this in order to bill for you (because we can’t diagnose.)
Major Medical Insurance
Major medical insurance refers to your primary health insurance plan. Benefits for massage therapy vary greatly by plan and may or may not offer out-of-network coverage.
Every health plan has a network of preferred providers. To find providers in-network, you need to search your plan’s “find a provider” page online. Most health plans give you the best benefits for seeing a provider within their network, though their “preferred provider” list may not include your preferred massage therapist.
Some plans offer the same benefits as in-network coverage which allows their customers to choose the best provider for them. Like myself, many massage therapists are not contracted with any networks (ie, out-of-network) and do not accept health insurance as a form of payment. As an out-of-network provider, I happily submit billing for my clients to be at least partially reimbursed by their health insurance plan (after paying at time of service).
Instead of billing for you, a therapist may simply give you a superbill or invoice, which you submit on your own as proof of payment to be reimbursed for health services.
Out of Network usually means you pay more out of pocket and wait longer to get reimbursed, however you get to see your preferred provider.
PIP and LNI Benefits
PIP is an acronym that means Personal Injury Protection and covers your medical expenses in the event you are injured in an auto accident. You pay for this coverage as part of your auto insurance. So if you are a passenger in someone else’s car, your own policy still covers you if injured. I can’t stress enough the importance of getting treatment if you are injured in an auto accident. See your doctor for an examination to determine the extent of your injuries. Whiplash injury symptoms often crop up weeks later and the scar tissue that forms can cause issues and chronic pain for years. Trust me, I know from personal experience of having multiple whiplash injuries and no treatment many years ago in a state that didn’t cover massage therapy or acupuncture. I’m still managing postural dysfunction and tension patterns in my body from 15-20 years ago!
LNI refers to insurance that covers you in the event you are injured at work. Your employer starts the paperwork process and you’ll have a primary care doctor overseeing the treatment process who can prescribe massage and other treatment.
Also, many providers not in-network with major medical plans will bill PIP and LNI for you so it’s not even an out of pocket expense!
Coverage through Health Savings Account or Flexible Spending Account
Massage Therapy is considered health care in WA state. Therefore, most HSA and FSA cards will cover the cost of massage therapy, even out of network (as long as the provider is set up to accept the cards). They sometimes want a diagnosis code to prove medical necessity, so be sure to check the requirements for your account or have a prescription on hand if they ask for it.
Don’t let health insurance benefits dictate whether or not you get the best massage therapy for you. If you benefit more from 1 session with a non-network provider than you do from several sessions with an in-network provider who isn’t the right fit, you’ll actually save money in the long run over paying multiple copays. Also, massage therapy benefits are often combined with other therapeutic modalities that cost more. For example, if you get 20 sessions total in a year and you plan to do massage and physical therapy, you may want to save your benefits for the more expensive treatment modality.
Hopefully this makes the health insurance world just a bit less confusing, at least when it comes to massage therapy!