Purpose: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use between urban and rural residents as well as whether differences in provider availability or patient cost-sharing explain the difference in utilization. Methods: Claims data from 237,500 claimants in 2 large insurance companies in Washington state for calendar year 2002 were analyzed, using adjusted clinical group risk adjustment for differences in disease burden and rural urban commuting area codes for rurality definition. Findings: The proportion of claimants using chiropractors was higher in rural than urban residents (44% vs 32%, P less than 0.001). Lack of conventional providers in rural areas did not completely explain this difference, nor did differences in patient cost-sharing or demographics. Among those who used chiropractors, those in urban areas had more chiropractic visits than users of chiropractic in rural areas. Conclusions: Among insured adults, use of chiropractic care was higher in rural than in urban areas. Reasons suggested for this difference in previous reports were not borne out in this data set.