Per-Visit Cap (Paramedical)
The per-visit cap is the maximum amount your insurance plan will reimburse for a single visit to a paramedical provider, such as a physiotherapist, chiropractor, or massage therapist. If the provider charges more than the cap, you are responsible for the difference. This cap ensures fairness and cost control by aligning payments with typical local pricing.
How It Works
Paramedical practitioners such as massage therapists and physiotherapists are not bound to a provincial fee guide and can set their own fees, which is why insurers apply per-visit reasonable and customary ceilings to limit excessive claims. These ceilings reflect the normal range of fees for a service in a given geographical area, and the limit applies when the provider charges more than that amount. Many Canadian group plans use these per-visit limits to manage costs and utilization, setting the amount covered per visit for services like massage therapy or chiropractic care. The cap may apply before coinsurance is calculated, so the insurer reimburses a percentage of the capped amount rather than the provider's full fee. Per-visit caps work alongside other cost-sharing mechanisms, including coinsurance, deductibles, reasonable and customary limits, and annual maximums, to define how much the plan actually covers.
Example:
Under a typical Canadian extended health plan, a member sees a registered massage therapist whose fee is higher than the plan's per-visit cap for massage therapy. The plan applies coinsurance to the capped amount rather than the full fee, so the member is reimbursed a percentage of the cap. The member personally pays both their usual share and the entire amount the therapist charged above the cap.
What to Watch For:
Different per-visit caps may apply to different paramedical practitioners under the same plan, so each discipline can have its own limit. Because these reasonable and customary limits can change over time without notice, ask about the limit that applies to your treatment, and consider requesting a predetermination of benefits before starting a course of treatment.
