What Are Out-of-Pocket Costs?

Out-of-pocket costs are medical expenses that you pay directly because they are not fully covered by insurance. These include deductibles, copayments, coinsurance, and any medical services that fall outside your plan’s benefits.

What affects out-of-pocket costs?

• Deductibles: The amount you must pay before your insurance starts covering services.
• Copayments: Fixed amounts you pay for doctor visits, prescriptions, or treatments.
• Coinsurance: A percentage of costs you share with your insurer after meeting your deductible.
• Out-of-network care: Seeing a provider outside your plan’s network can lead to higher costs or full responsibility for the bill.
• Medicare coverage gaps: While Medicare covers many expenses, some services—like dental, vision, or hearing aids—may require separate coverage or out-of-pocket payments.
• Prescription drugs: Costs depend on your plan’s formulary, whether the drug is generic or brand-name, and any coverage limits under Medicare Part D.

How Solace can help

A Solace advocate can help you understand your medical bills, navigate insurance benefits (including Medicare), and find ways to lower costs. If you're facing high out-of-pocket expenses, an advocate can also assist in identifying financial assistance programs, negotiating payment plans, reviewing claims for possible billing errors, or crafting appeals for denied claims.

What to do next

Worried about unexpected medical expenses? Explore cost-saving options and get the support you need: Find an advocate today.