Health Care Plans: Reasonable and Customary Charges

Have you ever wondered what your Extended Health Care plan actually covers?

Typically, Extended Health Care plans include coverage for the services of several types of healthcare practitioners, such as chiropractors and massage therapists.

There is a range of usual fees practitioners in each province charge for services.

Insurance companies use these “reasonable and customary” fees as the basis for pricing their benefit plans and determining the maximum eligible amount that they will reimburse. Most provider associations publish a suggested fee schedule for their practitioners.  

However, there is no requirement for them to charge according to this and fees for similar services can sometimes differ substantially from one practitioner to another.

Most paramedical expenses claimed by plan members fall within the reasonable and customary fee range. If a healthcare practitioner chooses to charge more, the member is responsible for the extra cost. Does this make the current system outdated?

Below, are the reasonable and customary charges for each type of practitioner in British Columbia, Canada (note: Some carriers do not publish their listing as they believe it helps protect the plan member, as some service providers will then charge the maximum allowable rate, as well as limit any fraudulent or excessive service fees.)

Your plan may not cover all the practitioners listed below, so make sure to check your contract or contact your group benefits representative if you are unsure.

Practitioners’ reasonable and customary charges:

  • Acupuncturist (For Initial assessment and Subsequent visit) – $100
  • Audiologist (per hour) – $125 
  • Chiropodist or Podiatrist – (For Initial assessment and Subsequent visit) – $100
  • Chiropractor – Initial assessment $135; Subsequent visit $60 
  • Dietician (per hour) – $150 
  • Massage Therapist (per hour) – $100
  • Naturopath – Initial assessment $210;  Subsequent visit $155 
  • Occupational Therapist (per hour) – $140
  • Optometrist (For Initial assessment and Subsequent visit) – $120 
  • Ophthalmologist (For Initial assessment and Subsequent visit) – $200
  • Osteopath – (For Initial assessment and Subsequent visit) – $120
  • Physiotherapist – Initial assessment $80;  Subsequent visit $135
  • Psychologist (per hour) – $190
  • Social Worker (per hour) – $175
  • Speech Therapist (per hour) – $120

This list only reflects the maximum Reasonable and Customary amount allowed per treatment. Claims will still be subject to the terms of your policy.

Usually, a plan limits paramedical services to one treatment, per service, per person, per day. It is the plan member’s responsibility to ensure their paramedical providers possess the credentials accepted by their insurance carrier.

We hope this guide helps you to better understand your Extended Health Care Plan.

If you’re an employer perhaps it will encourage you to review your plan, and whether change could potentially be beneficial for your employees Extended Health Care Plan.

Ly Siu
I am a dedicated, proven professional with more than 20 years of Benefits and Human Resources experience in both the private and public sector.  I will provide you and your employees with a customized and cost-effective benefit plan that gives you the greatest value, while meeting your organizational goals and budgets. My most important objective is to save you TIME and MONEY – so you can focus on managing your business operations.

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