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Reasonable and Customary Charges


Out-of-pocket Expense Cap

There's one advantage found in PPO or POS services that isn't found in fee-for-service plans. Both of these plans have what's known as an out-of-pocket expense cap. This cap is the amount you need to pay out-of-pocket for certain medical services or treatments before the insurance company pays for 100 percent of the reasonable and customary fee. These caps are useful when you decide to go outside of the network. For example, if you have met the deductible for your PPO plan, the insurance company will begin paying 80 percent of the reasonable and customary charges of your out-of-network doctor's bills with you paying the remaining 20 percent. Once the out-of-pocket expense cap is reached, the insurance company will then pay 100 percent of the reasonable or customary fee of a provider. It's also important to note that only certain health care items can go toward your out-of-pocket expense cap. To learn more about out-of-pocket expenses, click here.

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