If you’ve been dealing with persistent back pain, a stiff neck that just won’t let up, or muscle tightness that disrupts your daily routine, medical massage might be exactly what your body needs to heal. At Circle Wellness, we believe in accessible, restorative care—and that includes helping you understand how to use your insurance to support your wellness journey.
If you’re covered under the New York State Health Insurance Program (NYSHIP), especially the Empire Plan, there’s a real opportunity to get medical massage covered. The key? Navigating the system with clarity and confidence.
We’ve simplified the process into easy-to-follow steps so you can get the relief you need without added stress.
Step 1: Understand Your NYSHIP Coverage
NYSHIP is a comprehensive health insurance program for New York State employees, retirees, and their families. The Empire Plan, one of its major offerings, often covers out-of-network services like medical massage when deemed medically necessary.
Here’s how to begin:
- Contact NYSHIP: Call 1-877-769-7447. Choose option 1 for UnitedHealthcare and ask about massage therapy under the Managed Physical Medicine Program.
- Ask the Right Questions:
- Does my plan cover medical massage?
- Is prior authorization required?
- What documentation is needed?
- What’s my out-of-network deductible?
- Visit the NYSHIP website: Check your plan’s Summary of Benefits and look under “Physical Medicine” or “Outpatient Services.”
Understanding your benefits is the first step in turning your massage care into a covered medical necessity.
Step 2: Get a Doctor’s Prescription
NYSHIP coverage depends on a medical necessity—this means a licensed healthcare provider must prescribe massage therapy to treat a specific condition such as chronic pain, post-injury rehabilitation, or muscular dysfunction.
What to do:
- Visit your physician or specialist and explain your symptoms clearly: “I’ve had consistent lower back pain impacting my ability to function. Can you prescribe massage therapy?”
- Make sure the prescription includes:
- A diagnosis and ICD-10 code (e.g., M54.5 for low back pain)
- A specific recommendation for massage therapy (e.g., “One session per week for 6–8 weeks”)
Your prescription serves as clinical proof that your massage treatment is part of a broader care plan—not just a luxury.
Step 3: Choose a Qualified Massage Therapist
At Circle Wellness, our Licensed Massage Therapists (LMTs) are highly experienced in providing medically targeted care. For NYSHIP reimbursement, the therapist must be licensed and provide documentation suitable for insurance claims.
Here’s what to look for:
- Verify Licensing: Only New York State-licensed massage therapists are eligible for NYSHIP reimbursement.
- Discuss Billing Options:
- Some LMTs submit claims directly.
- Others may ask you to pay upfront and provide the documentation needed for you to file a claim yourself.
- Out-of-Network Coverage: Most medical massage providers are considered out-of-network. Confirm what portion of the costs NYSHIP will reimburse after the deductible.
Choosing a therapist familiar with medical massage and insurance requirements ensures a smoother process and maximizes your benefits.
Step 4: Submit Your Claim Correctly
If your therapist submits claims for you, make sure they have all necessary information. If you’re submitting the claim yourself, follow this process:
- What You’ll Need:
- A completed NYSHIP claim form (available on myuhc.com)
- A copy of your doctor’s prescription
- An itemized receipt that includes: your therapist’s name and license number, date of service, CPT code (e.g., 97124 for massage therapy), and total cost
- Mail Your Documents To:
UnitedHealthcare
P.O. Box 1600
Kingston, NY 12402-1600
Processing can take up to 30 days, so keep a copy of everything and check your claim status via phone or online.
Step 5: Manage Costs and Maintain Eligibility
Even with approval, some out-of-pocket expenses may apply. Here’s how to plan:
- Deductibles: NYSHIP’s Empire Plan has a $1,250 out-of-network deductible. Once met, you may be reimbursed for 80% of eligible charges.
- Session Limits: Therapy must remain medically necessary. If your doctor prescribes multiple weeks, ask them to reevaluate and renew as needed.
- Appeals: If your claim is denied, request a written explanation. You can file an appeal with supporting documentation from your doctor and therapist.
Tips to Improve Your Approval Odds
Even with approval, some out-of-pocket expenses may apply. Here’s how to plan:
Keep a Wellness Log
Coordinate Care
Be Proactive
Why Medical Massage Matters
Medical massage isn’t just about temporary relief—it’s an evidence-based approach to improving circulation, reducing pain, and enhancing your body’s ability to heal. For individuals covered by NYSHIP—whether you’re working long shifts, recovering from an injury, or simply trying to manage chronic stress—this therapy can be an essential component of your healthcare.
At Circle Wellness, we’ve seen firsthand how targeted massage therapy transforms lives. By taking the steps to get it covered, you’re not just investing in short-term comfort—you’re supporting long-term well-being.
