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.
For example, your plan might pay up to $40 per visit for massage therapy, regardless of the therapist’s actual fee. The cap may apply before coinsurance is calculated, meaning the insurer reimburses a portion of that capped amount.
Example:
If your massage therapist charges $75 and your plan’s per-visit cap is $40 with 80 percent coinsurance, the plan pays $32 (80 percent of $40) and you pay $43.
What to Watch For:
Ask your provider about their fees before treatment. Some plans set different per-visit caps for various practitioners, and higher charges are always your responsibility.
