The whole point of updating the book was to really start creating a movement toward Health Care Integration for all of the massage profession. This is not to separate out the spas/relaxation focused businesses as stress reduction is also a big part of healthcare. (It will take longer for carriers to pay for massage for stress reduction as currently they only pay for medically necessary massage for physical symptoms).

From my over 38 years of billing all sorts of insurance and watching our profession not get the support it needs to be a part of Health Care, I am working on creating a plan to make it so.

How to Get Massage Therapy Covered by Health Insurance in Every State

A Comprehensive Plan Built on Washington State’s Every Category of Provider Law

Massage therapy did not enter Washington State’s insurance system because insurers suddenly recognized its value. It entered because lawmakers intervened, patients demanded access, and providers learned how to work inside a system that was never designed for them. Every other state can do the same — and the legal groundwork is already laid.

This is a plan for making that happen, state by state, across the entire country.

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THE LEGAL FOUNDATION ALREADY EXISTS

Three legal pillars give every state the authority it needs to mandate insurance coverage for massage therapy. What has been lacking is not permission — it is coordinated action.

Washington State’s Every Category of Provider Law (1995)

Washington enacted one of the strongest and earliest provider nondiscrimination statutes in the U.S.: RCW 48.43.045. The Every Category Law. The intent was simple but radical for its time. If a health plan covers a service, it cannot discriminate against a licensed provider who is legally allowed to perform that service. Insurers could no longer say “we cover this treatment, but only if a doctor or physical therapist does it.”

The law requires insurers to reimburse any licensed health care provider for covered services when the service is within the provider’s scope of practice, when the service is medically necessary, and when the service would otherwise be covered if performed by another provider type.

Washington also explicitly defines massage therapy as a health care service under RCW 18.108. That statutory definition is crucial. Without it, insurers default to treating massage as a personal service and deny claims on definitional grounds before the clinical argument even starts.

That law did not magically make insurance companies friendly to massage. What it did was create legal footing. It gave massage therapists something far more powerful than approval: standing.

The Supreme Court Breakthrough: Kentucky Association of Health Plans v. Miller (2003)

For years, insurers argued that state provider nondiscrimination laws were preempted by ERISA, the federal law governing employer-sponsored health plans. This argument effectively froze other states from acting. The legal uncertainty was real enough to stall legislative progress for a decade.

In 2003, the U.S. Supreme Court ended that uncertainty. The Court ruled in Kentucky Assn. of Health Plans v. Miller that state any-willing-provider and nondiscrimination laws are not preempted by ERISA, provided they meet a two-part test: the law must be specifically directed toward insurers, and it must substantially affect the risk-pooling arrangement between insurer and insured.

Both conditions are easily met by well-drafted Every Category legislation. Washington’s law was retroactively validated by this decision. Every state now has clear constitutional authority to act. The barrier was never the law — it was the absence of coordinated political will.

See the complete history of the Every Category Law in WA and how Deborah Senn, the insurance commissioner at the time, fought the insurance companies and won!

The ACA Reinforces the Principle (2010)

ACA Section 2706(a) added a federal floor: group health plans shall not discriminate against any health care provider who is acting within the scope of their license. Federal enforcement has been inconsistent, but the statute gives advocates additional language to cite and creates a baseline that state laws can build upon. Importantly, the ACA did not override Washington’s law — it supplemented it.

The bottom line: the constitutional groundwork is already laid. ERISA is no longer the barrier insurers claim it is. Washington provides a working, defensible model. Other states can replicate it now.

THE ERISA GAP — BE HONEST ABOUT IT

State Every Category laws do not reach self-insured employer plans operating under ERISA, which cover roughly 60 percent of workers with employer-sponsored insurance. This is a structural limitation that advocates need to acknowledge honestly rather than paper over.

However, fully-insured plans — which state laws do govern — cover a substantial portion of the market and self-insured plans often adopt state coverage standards voluntarily for administrative uniformity. The strategy is to establish the state mandate first, then pursue employer-side advocacy, union contract negotiations, and longer-term federal legislative action to close the ERISA gap.

Acupuncture’s success in Medicare shows how this works in practice. Acupuncture advocates won Medicare coverage by starting narrow — targeting chronic low back pain only, at a moment when Medicare was under intense pressure to address the opioid crisis. They accepted physician oversight and visit caps as initial conditions. Coverage was granted. Now the expansion work begins from a position of inclusion rather than exclusion. Massage therapy can follow the same path.

STATE-BY-STATE READINESS

Not every state starts from the same position. Effective advocacy means understanding where each state stands and choosing the right approach for that context.

Are massage therapists considered to be healthcare providers in your state?

Does your state have an Every Category law or any-willing-provider language that would make it so massage therapists were allowed to become contracted providers, bill and get paid by healthcare insurance?

Does your state have opioid reduction legislation or pain management statutes that name massage therapy as a possible provider of services for this?

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THE FIVE-PHASE PLAN

Phase 1 — Define the Profession in Law (Years 1 to 2)

This is the non-negotiable prerequisite. Insurers rely on vague or absent statutory definitions to treat massage as a personal service and deny claims on definitional grounds. Without clear health care language in statute, every subsequent strategy is weakened.

Audit every state’s existing massage therapy licensing statutes for health care language. Draft model statutory language defining massage therapists as health care providers — adaptable to each state’s regulatory structure, but consistent in its core meaning. Ensure scope of practice language explicitly authorizes assessment, documentation, and functional goal-setting. In unregulated states, pursue state-level licensure as the first legislative priority.

Most critically, the profession needs to agree on one unified definition of clinical massage therapy. Today massage therapy is defined 40 different ways across 40 states that have licensing laws. This fragmentation is the profession’s biggest self-inflicted vulnerability. Insurers have stepped into that definitional vacuum and used it to restrict coverage. When the profession does not present a clear, unified definition rooted in clinical purpose, insurers default to their own restrictive interpretations. That stops when we define ourselves.

Phase 2 — Build the Coalition (Years 1 to 3)

Massage therapy alone cannot win insurance reform through lobbying power. But massage therapy positioned within a broader pain management, opioid reduction, and integrative care coalition can.

Clinical partners to recruit include chronic pain physicians, physical therapy associations, chiropractic associations, hospital integrative medicine departments, and VA healthcare advocates. Patient advocates to bring in include the American Chronic Pain Association, opioid recovery organizations, cancer patient support groups, and veteran service organizations. On the employer and insurance side, state chambers of commerce respond to cost-savings arguments, labor unions can negotiate massage coverage into collective bargaining agreements, and workers’ compensation system stakeholders are natural allies.

One practical tactic worth emphasizing: have licensed therapists provide chair massage to state legislators and their staff before committee hearings. This sounds simple. It is surprisingly effective. Policy debates about massage therapy are often conducted by people who have never experienced clinical massage. Humanizing the profession in person changes the conversation.

Phase 3 — Introduce and Pass Every Category Legislation (Years 2 to 4)

The model legislation needs four core elements. First, a definitions section that explicitly includes licensed massage therapists in the definition of health care provider. Second, a provider nondiscrimination section that prohibits coverage denial based on provider category when the service is within scope, medically necessary, and would be covered if performed by another provider type. Third, carrier obligation language requiring insurers to develop and publish credentialing criteria for all licensed provider categories, with written reasons required for any denial. Fourth, an enforcement section giving the insurance commissioner authority to receive and investigate complaints, with civil penalties for willful violations and a private right of action for affected providers.

The drafting must satisfy the Miller two-part test: the law must be specifically directed toward insurers, not employers, and must substantially affect the risk-pooling arrangement between insurer and insured. Get that right and ERISA preemption arguments fail.

For legislative strategy, identify a champion legislator in each target state — preferably someone on the health committee with personal or constituent experience with massage therapy. Brief the state insurance commissioner before the bill is introduced. Commissioners who become administrative allies can be as powerful as legislative sponsors.

Phase 4 — Build the Billing and Compliance Infrastructure (Years 3 to 6)

Washington’s history contains a critical lesson: passing legislation without a ready profession produces denials, billing errors, and insurer pushback that undermines the law’s intent. The law opens the door, but therapists still have to walk through it correctly. Infrastructure must be built in parallel with legislative campaigns.

When the law was passed here, one insurance company in particular required training in charting. Our AMTA-WA chapter also provided training on HIPAA and other legal requirements around billing and being a healthcare provider.

This means developing a national clinical documentation standard — a model SOAP note format, functional outcomes language, and medical necessity framework that meets insurer audit standards. It means creating state-by-state credentialing guides and building CAQH ProView profiles for LMTs pursuing insurance work. It means advocating for insurance billing fundamentals as a required competency in massage therapy school curricula. And it means establishing a voluntary national outcomes database where therapists can submit clinical outcome data — pain scores, functional status, cost comparisons. That data becomes the profession’s most powerful legislative asset in the years that follow.

Phase 5 — Federal Strategy: Medicare, Medicaid, and ERISA Reform (Years 5 to 10)

Three parallel federal tracks run simultaneously.

On Medicare, follow the acupuncture model. Introduce a narrowly scoped coverage bill targeting chronic low back pain, cancer-related pain, and post-surgical recovery. Accept physician oversight and visit caps as initial conditions. Once covered for those conditions, expand indications through outcomes data. The key is getting inside the system first.

On Medicaid, pursue State Plan Amendments in states where massage is already considered to be healthcare providers. (WA State is in the process of doing just that.) In parallel, push for managed care plan inclusion — many Medicaid managed care plans can cover massage as a value-added benefit without a full SPA. Build the cost-savings evidence base around reduced emergency room utilization, reduced opioid prescribing, and functional improvement in chronic pain populations. This is the argument that moves Medicaid administrators.

On ERISA, work with congressional allies to introduce an amendment either exempting provider nondiscrimination laws from ERISA preemption or extending ACA Section 2706 enforcement to self-insured plans. This is a long-game play. Build the coalition and the evidence base first. Establish a national Political Action Committee focused exclusively on massage therapy policy — paid, professional federal advocacy is not optional at this level.

On VA coverage, expand the VA Community Care pathway, which currently offers the most consistent independent coverage pathway for LMTs. Document outcomes rigorously. VA outcomes data becomes congressional testimony. Learning to bill the VA will also get you connected with the representatives for the VA and could be the start of being able to give input into the VA policies and procedures. (AMTA National has been working on that, but I think it could also come from the local massage therapists doing the billing and working with this population.)

THE CLINICAL FRAMING IMPERATIVE

Legislative strategy alone is insufficient. The profession must collectively shift how it presents itself — not to abandon holistic values, but to speak fluently in the language insurers, regulators, and legislators actually use.

Insurance does not pay for experiences. It pays for conditions.

Washington insurers did not start paying because therapists changed their hands-on work. They started paying because therapists changed how they documented and presented that work.

Words and phrases that need to retire: relaxation, stress relief, maintenance massage, wellness session, balancing energy, general wellbeing, holistic healing.

Words and phrases that get claims paid: functional limitation secondary to diagnosis, pain interference with activities of daily living, post-injury soft tissue mobilization, neuromuscular reeducation, documented musculoskeletal condition, medical necessity per referring physician.

Documentation must include ICD-10 coded diagnoses — the M54 series for spinal pain, M25 for joint pain, M79 for soft tissue disorders, M62 for muscle conditions, S-codes for injuries, G89 for chronic pain. Every claim must tie treatment to a diagnosable condition with functional goals and measurable progress. A physician referral or prescription must be on file. SOAP notes must support every billed unit.

This is not selling out. It is translation. The hands-on work does not change. The professional language around it does.

We need to get the CPT code for massage (97124) updated to reflect clinical massage and update the code for manual therapy (97140) to include massage therapists.

ANTICIPATING INSURER OBJECTIONS

Insurers will resist. They always have. Their resistance follows predictable patterns, and every advocate and therapist should have prepared responses.

When insurers say massage is not medically necessary, the response is that medical necessity is determined by the condition and the physician’s referral — not by the profession delivering treatment. Present the ICD-10 coded diagnosis, the physician prescription, the documented functional limitations, and the clinical guidelines naming massage therapy as a recommended intervention. The CDC opioid prescribing guidelines, the American College of Physicians low back pain guidelines, and the National Center for Complementary and Integrative Health evidence summaries all name massage therapy as evidence-supported.

When insurers claim insufficient evidence, cite the Cochrane reviews, NIH-funded research, and clinical practice guidelines that specifically recommend massage for low back pain, fibromyalgia, cancer-related pain, and post-surgical recovery. The evidence base is substantial. It has simply not been organized into a well-packaged advocacy document. That is a solvable problem.

When insurers raise ERISA preemption, acknowledge the limitation for self-insured plans honestly — then pivot to the plans the law does reach, and document every denial from ERISA plans for future federal advocacy.

When insurers argue that coverage will increase costs, present Washington State data showing that massage coverage with appropriate medical necessity requirements and visit limits did not produce runaway costs. The opioid cost-offset argument is particularly powerful: one avoided opioid prescription, one avoided emergency room visit, one avoided surgery pays for many massage therapy sessions. Coverage is risk reduction, not new expense. (See the AMTA report: American Massage Therapy Association. The Value and Efficacy of Massage Therapy in Integrated Health Care Available from: https://www.amtamassage.org/uploads/cms/documents/aca_book_final.pdf )

When insurers say they cannot credential massage therapists, present the existing infrastructure: state licensure requirements, NCBTMB board certification (although our Board Certification could use an update), the MBLEx national examination, CAQH ProView profiles, and professional liability insurance requirements. The infrastructure exists. What has been missing is organized presentation to insurer credentialing departments.

WHAT EVERY INDIVIDUAL THERAPIST CAN DO NOW

Structural reform is built from individual acts of professional engagement.

Start with your state law. Look up your state’s massage therapy licensing statute. Does it use health care provider language? Does your state have any provider nondiscrimination law? Visit your state insurance commissioner’s website. This is not optional — it is your professional foundation. Most massage therapists skip this step entirely, which is exactly why insurers get away with policies they legally should not.

Get credentialed even before you need it. Create a CAQH ProView profile. Apply to provider networks. Each application, even if denied, generates data about exclusion patterns that advocacy organizations can use.

Track functional outcomes with your clinical patients. Use validated outcome measures. Submit that data to the AMTA research database. The profession’s evidence base can only be built by practicing therapists.

Join your state AMTA chapter or better yet, start your own State Association as you will be able to do more. Attend state legislature health committee hearings. When your association issues a legislative action alert, respond to it. Political engagement at scale is how Washington’s law was won — not by associations alone, but by constituents showing up.

KEY LEGAL REFERENCES

Washington Every Category Law: RCW 48.43.045 https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.045

Washington Massage Therapy Health Care Definition: RCW 18.108 https://app.leg.wa.gov/rcw/default.aspx?cite=18.108

Regulatory Implementation: WAC 284-170-270 https://app.leg.wa.gov/wac/default.aspx?cite=284-170-270

Supreme Court ERISA Decision: Kentucky Assn. of Health Plans v. Miller (2003) https://www.law.cornell.edu/supct/html/00-1471.ZS.html

ACA Section 2706: 42 U.S.C. § 300gg-5

State Coverage Status Chart and Resources: https://www.massagepracticebuilder.com/massage-insurance-billing-resources/

History of Massage Therapy in Health Care: https://www.massagetherapynexus.com/history-of-massage-therapy-in-healthcare-2000-2024/

Insurance coverage for massage therapy is not a favor insurers will grant because they are persuaded. It is a legal right the profession must claim — methodically, state by state, with documented practice, strategic pressure, and professional maturity.

Washington opened the door in 1995. The Supreme Court cleared the legal path in 2003. The ACA added federal language in 2010. Every tool needed is already in place.

What happens next depends on whether the profession shows up for itself.

Not because it doesn’t belong there.

But because we were never taught how to participate.

When I first started writing about insurance billing back in 2005 my goal was just to share what I had learned the hard way.

Many people have tried billing insurance only to give up because of the low pay and increasing frustrations with our medical systems and payment processes.

The thing is that more and more plans are covering massage in every state.

The VA covers it.

Workers’ comp relies on it.

Auto injury claims depend on it.

Medicare Advantage plans are expanding it.

Employer-funded plans are quietly including it.

The opportunity is here.

The systems on learning how to bill are lacking. The support systems for therapists learning to bill and navigate billing are missing. We are also not at the table with the insurance carriers, legislator and medical providers to make sure that massage therapy is a part of healthcare and are paid fairly.

Learning how to bill insurance is not just a business skill—it is a positioning shift for the entire profession. When massage therapists understand how to operate inside the healthcare system, they move from being viewed as optional or “nice to have” to being recognized as providers delivering measurable, outcome-based care. That shift matters. Because in healthcare, payment is not based on passion or popularity—it is based on documentation, data, and demonstrated results. The more therapists who can show that their work improves function, reduces pain, and contributes to recovery, the harder it becomes for insurers and policymakers to ignore or undervalue what we do.

This is where advocacy becomes grounded in reality instead of opinion. For years, massage therapists have argued that they deserve better pay, broader coverage, and more respect—but without consistent data and participation in the system, those arguments have been easy to dismiss. Insurance billing changes that. Every properly submitted claim, every SOAP note showing progress, and every case that demonstrates medical necessity becomes part of a larger body of evidence. That evidence is what drives fee schedules, coverage decisions, and policy changes. In other words, billing is not just about getting paid—it is about creating the proof needed to justify being paid fairly.

It also changes the power dynamic. When therapists understand how insurance works, they are no longer dependent on employers, chiropractors, or clinics to access that system. They can participate independently, negotiate from a more informed position, and make strategic decisions about which cases and payers are worth their time. This reduces one of the biggest frustrations in the profession—feeling stuck in low-paying jobs with little control. Knowledge creates leverage, and leverage is what leads to better working conditions, not just better reimbursement.

One of the most overlooked benefits of insurance literacy is that it unifies the profession around a clearer identity. When therapists begin to document care in terms of function, outcomes, and medical necessity, it creates a shared language that can be used across states, settings, and specialties. That consistency is exactly what is needed to push for larger reforms—like fair reimbursement rates, inclusion in more plans, and stronger legal recognition. Without that foundation, advocacy efforts stay fragmented and emotional. With it, they become strategic and much harder to ignore.

Ultimately, learning to bill insurance is about more than navigating paperwork—it is about stepping into a role the profession has historically avoided. It is about showing up in a system that already exists, understanding its rules, and using them to push for change. When enough therapists do that consistently and ethically, the conversation shifts from “Why should massage be covered?” to “How do we expand and fairly reimburse a service that is already proving its value?” That is the level where real change happens.

If we are not at the table, we will be on the menu.

("If we're not at the table, we're on the menu" is a political and business adage meaning that those who lack a seat in negotiations or decision-making processes will likely become victims of those decisions. It emphasizes that failing to actively participate in shaping outcomes—especially in international affairs or high-stakes business—results in being disadvantaged or exploited by stronger parties.)

If you are a self-starter, this Field Guide can get you going…but the best option is to get the full book. (In Paperback, Kindle and PDF download)

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