The American Massage Therapy Association (AMTA) has been working on getting massage therapy covered by Medicare Advantage Plans since 2018.
August 2018 – AMTA began an outreach effort with approximately 700 Medicare Advantage insurance companies encouraging them to follow the Center for Medicare Services recommendations by covering medically-approved massage therapy provided by state licensed massage therapists. While coverage of massage therapy is not automatic, AMTA is asking Medicare Advantage plans to consider it for 2019 and 2020. AMTA Website
Yesterday I attended the webinar they put on called Medicare Advantage 101 led by ATI Advisory and AMTA’s National Government Relations team. ATI Advisory is a firm dedicated to helping public and private healthcare leaders solve complex healthcare challenges through objective research, deep expertise, and practical solutions.
Presenters:
- Tyler Cromer, Principal, ATI Advisory
- Joseph June, Analyst, ATI Advisory
- James Specker, Senior Director, Government and Industry Relations, AMTA
- Martha Rinker, Government Relations Policy and Research Analyst, AMTA
- Deborah Outlaw, Federal Lobbyist, The Outlaw Group
Medicare Advantage 101
Medicare Advantage, also known as Medicare Part C, is an alternative to traditional Medicare offered through private insurance companies that contract with Medicare. These plans provide all the benefits of Original Medicare (Parts A and B), often include additional services like vision, dental, and hearing, and sometimes cover prescription drugs (similar to Medicare Part D). Medicare Advantage plans typically bundle these services into a single plan, allowing beneficiaries to receive all their healthcare needs in one place.
In Original Medicare, beneficiaries can see any doctor who accepts Medicare. In contrast, most Medicare Advantage plans have provider networks, which may limit choice or require higher costs for out-of-network providers. Medicare Advantage also sets an annual cap on out-of-pocket expenses for Part A and Part B services, which Original Medicare lacks, providing financial protection if extensive care is needed.
Pros and Cons
Pros:
- Potentially lower premiums (some plans have $0 premiums)
- Extra benefits like vision, hearing, dental, and wellness programs
- Out-of-pocket maximum for Part A and B services, providing a safety net
Cons:
- Restricted provider networks (may not cover all doctors and hospitals)
- Coverage and costs can vary widely, making it essential to review plans carefully each year
- Plans can require prior authorization for certain services, adding a layer of approval before receiving care
Just so you know…Medicare Advantage’s popularity suggests that many beneficiaries appreciate the added benefits and simplicity of a single plan. However, critics argue that expanding the role of private insurers within Medicare represents a movement toward privatizing what has historically been a public program. They warn that the shift could undermine the long-term sustainability and universality of Medicare, possibly increasing costs and reducing care options for beneficiaries in the future.
The debate around Medicare Advantage is essentially about the future direction of Medicare: should it remain primarily a public program, or should it evolve into a hybrid model that leans increasingly on private insurers? The growth of Medicare Advantage points toward the latter, reflecting a broader shift toward privatization in American healthcare policy.
Massage Insurance Billing 101
First you might want to check to see what plans are covering massage therapy in you area. AMTA said they would be providing the list, but you can also start checking in your local Facebook Groups for Information or join my Facebook Massage Insurance Billing Group.
Some carriers will require that you become a credentialed provider with them. Each of them has their own system for doing that, so you will need to get that information from them directly. Some carriers will allow you to bill and get paid without being credentialed.
What you will need:
- An NPI number. Online: Go to https://nppes.cms.hhs.gov/ ,
click on “Apply Online,” and follow the steps. Most of the registration process is straightforward. When you get to “Taxonomy,” select “22: Respiratory, Rehabilitative & Restorative Service Provider,” then scroll down to “Massage Therapist.”Contact the NPI Enumerator program via any of the following methods:
Phone: 800-465-3203
TTY: 800-692-2326
Email: customerservice@npienumerator.com
Mail: NPI Enumerator, PO Box 6059, Fargo, ND 58108-6059 - You will need to be HIPPA Compliant. See my book my book the Massage Insurance Billing Manual (to purchase PDF) or Paperback/Kindle on Amazon.
- You will need to know how some of the laws around billing and working with insurance regarding fraud and fee setting. You will need to learn how to fill out a billing form using specific billing codes, how to set your fees, Learn the Basics of Billing with my book the Massage Insurance Billing Manual (to purchase PDF) or Paperback/Kindle on Amazon.
Challenges in Working with Insurance
In WA State we have been able to bill Health Insurance Plans since about 1996, when the insurance commissioner at that time (Deborah Senn) created a law that mandated coverage of massage therapy here. It was fought by the insurance companies but Senn won. (You can see the history of this important legislation here)
Over the many years we have been faced with dwindling allowable fees, decreasing benefits and network adequacy issues. The low fees are always the main problem and may be a challenge when billing these Medicare Advantage Plans. You will have to weigh out the pros and cons of billing insurance. I can tell you that it won’t always be easy: more paperwork (charting, billing, following up, appeals etc), but on the other hand massage therapy is getting to be more accepted as a viable part of healthcare.
There is also power in numbers. The more massage therapists we have billing and understanding the process as well as clients receiving massage under these benefits, the more people we will have when it comes time to advocate for the massage profession and work for fair pay from insurance carriers.
Dec. 11, 2018 post from www.massagepracticebuilder.com
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.
AMTA News Brief September 4, 2018: AMTA Reaching Out to 700 Medicare Advantage Plans
The Centers for Medicare & Medicaid Services (CMS), the federal government department that administers the Medicare program, recently issued guidelines that named massage therapy as a medically-approved, non-opioid treatment alternative.
AMTA News November 28, 2018: CMS Announces Up to 270 Medicare Advantage Plans Will Include Massage Therapy in 2019
The CMS Press release says:
Medicare Advantage enrollment is projected to increase to an all-time high from the current enrollment of 20.2 million to 22.6 million in 2019, an 11.5 percent increase compared to 2018.
As a result of the new flexibilities on supplemental benefits available for the first time in 2019, about 270 plans are providing nearly 1.5 million enrollees with access to the following new types of benefits:
- Expanded health related supplemental benefits, such as adult day care services, in-home support services, caregiver support services, home-based palliative care and therapeutic massage; and
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.
With the combination of Medicare recognizing massage therapy and the precedent set in WA State, massage therapy is on its way into healthcare – whether we want it or not. There are many issues in being a part of healthcare that we are not prepared for. We do not have enough in the way of advocacy in place to talk to the insurance carriers and legislators who create the laws. We need to be at the table or we will be on the menu.