Reasonable & Customary

Reasonable and customary refers to the typical fee charged for a particular service in your geographic area. Insurers use this standard to determine how much they will reimburse for eligible expenses. If a provider charges more than the reasonable and customary rate, you must pay the difference.

‍

This standard prevents overbilling and keeps plan costs fair for all members. Each insurer sets its own reasonable and customary fee tables, which are updated regularly to reflect local pricing trends.

‍

Example:

‍

If the reasonable and customary rate for a physiotherapy visit is $80 and your provider charges $100, you pay $20 in addition to any coinsurance.

‍

What to Watch For:

‍

Ask your provider whether their fees align with your insurer’s schedule. Repeatedly exceeding R&C limits can significantly increase out-of-pocket expenses.