Out-of-Pocket Costs
Out-of-pocket costs are the health care costs you pay yourself. These can include your deductible, copays, and coinsurance for covered services. You usually pay these costs when you visit a doctor, fill a prescription, or receive other medical care. The amount you pay can depend on your plan and the type of service you receive.
Last updated: October, 2026
Key Takeaways
- Out-of-pocket costs are the costs you pay for care yourself.
- These costs can include your deductible, copays, and coinsurance.
- Your out-of-pocket costs can be different based on your plan, the service you receive, and your out-of-pocket maximum.
- Using in-network providers usually helps keep these costs lower.
- Knowing these costs can help you plan your health care budget.
What are Out-of-Pocket Costs?
Out-of-pocket costs are the amounts you pay for health care that are not paid by your health plan. These costs often include your deductible, copays, and coinsurance.
For example, you may pay a copay for a doctor visit or coinsurance for a test or procedure. Your out-of-pocket costs can change based on the service you receive, whether you have met your deductible, and whether you stay in-network. These costs matter because they affect what you may need to pay when you use care, even if you have coverage.
How This Shows Up in Real Life
Let's say you go to an in-network doctor for a sick visit and pay a $30 copay. Later, you need lab work and pay 20% coinsurance after meeting your deductible. Those are both out-of-pocket costs because they are amounts you pay yourself. Common examples of out-of-pocket costs include:
- Copay: A fixed amount you pay for a service, such as $30 for a doctor visit
- Coinsurance: A percentage of the cost you pay after meeting your deductible, such as 20% for lab work
- Deductible: The amount you pay before your plan starts sharing costs, such as the first $1,000 of care
- Prescription costs: Copays or coinsurance for covered medications, depending on the drug tier
How Out-of-Pocket Costs Affect What You Pay
Out-of-pocket costs have a direct effect on what you spend during the year for health care. A plan with a lower monthly premium may have higher out-of-pocket costs when you get care. A plan with a higher monthly premium may help lower what you pay at the doctor, pharmacy, or hospital.
That is why it helps to look at both monthly premium costs and out-of-pocket costs when you pick a plan. This can help you avoid surprise bills and choose coverage that better fits your budget.
Where to Find This in Your Plan Details
To check your out-of-pocket costs, you can look at:
- Your Summary of Benefits and Coverage (SBC)
- Your Schedule of Benefits
- Your member handbook or policy documents
- Your Ambetter Health online member account
These resources can help you check your deductible, copays, coinsurance, and out-of-pocket maximum.
How This Changes Across Marketplace Plans
Out-of-pocket costs can be different across Marketplace health insurance plans. The amount you pay often depends on the plan category, network rules, and the type of care you receive.
Some plans trade lower monthly premiums for higher costs when you use care. Others have higher premiums but may help lower what you pay when you visit a doctor, fill a prescription, or receive treatment.
- Lower-premium plans often have higher out-of-pocket costs.
- Higher-premium plans may make out-of-pocket costs more predictable.
- Bronze, Silver, and Gold plans balance monthly premiums and out-of-pocket costs differently.
- Network rules can affect how much you pay.
- It helps to compare both monthly and care-related costs.
| Plan Tier | Monthly Premium | Typical Cost Sharing |
|---|---|---|
| Monthly Premium | Some plans cost less each month but more when you get care | Lower premiums can come with higher out-of-pocket costs |
| Deductible | Some plans have a higher deductible than others | You may pay more before the plan starts sharing costs |
| Insurance Plan Category | Bronze, Silver, and Gold insurance plans balance premiums and out-of-pocket costs differently | Lower-tier plans may cost less each month but more when you get care, while higher-tier plans may have higher premiums but lower out-of-pocket costs |
| Cost Sharing | Copays and coinsurance can be different by plan | Your costs for visits, tests, and prescriptions can change |
| Provider Network | Out-of-network care may cost more or may not be covered | Staying in-network usually helps keep costs lower |
FAQs About Out-of-Pocket Costs
Out-of-pocket costs usually include your deductible, copays, and coinsurance. These are the amounts you pay yourself for covered care. Some non-covered services may also lead to costs you pay on your own. Monthly premiums typically do not count toward your out-of-pocket costs, and some plans may not count certain out-of-network expenses.
No. Your monthly premium is what you pay to keep your health coverage active. Out-of-pocket costs are what you pay when you get care. Both can affect your total health care spending during the year.
Usually, yes. Copays or coinsurance for covered prescription drugs are often part of your out-of-pocket costs. The amount can be different based on the drug and its tier.
Your costs depend on your plan, the services you use, and whether you stay in-network. Two people can have different out-of-pocket costs even if they both have health insurance. The type of care you receive during the year can also affect what you pay.
You can help lower your costs by using in-network providers and checking your plan details before getting care. Picking a plan that matches your health needs can also help. Understanding your deductible, copays, and network rules can make costs easier to manage.
Have questions? Let’s walk through how this works with your plan.
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.
Related Terms
What Is Coinsurance in Health Insurance?
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Copay
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Learn what a copay is, when you pay it, and how copays apply to doctor visits, prescriptions, and other covered healthcare services.
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What Is an Out-of-Pocket Maximum?
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Understand what your out-of-pocket maximum means and how it protects you from high medical costs.
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What Is a Deductible in Health Insurance?
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Learn what a deductible is, how it works and how it affects your health care costs.
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What Does In Network Mean?
09/30/2026
Understand what in-network means and why choosing in-network providers saves you money. Find in-network care with Ambetter Health.
Learn MoreHave questions? Let’s walk through how this works with your plan.
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.
Sources:
Healthcare.gov - Out-of-Pocket Costs, Save on Out-of-Pocket Costs, Out-of-Pocket Maximum