Out of Pocket Expense

Out of Pocket Expense Meaning

Out of pocket expense refers to the direct payment which is generally made in form of cash by one which in future may or may not be borne by an external third party as it does not fall under their liabilities. In business it can be the employee’s spending which one has spent for business- or work-related purpose first out of his/her own pocket and then these get reimbursed by the company or business.

Explanation

Out of pocket pockets ranges to a varied number of things. It may or may not be reimbursed by the third party, which depends on a case to case basis. Usually, for businesses or companies, when employees pay from their pocket the business-related or work-related expenses, it gets easily reimbursed. In contrast, for medical insurance, there is certain kind of payments like prescription fee which the customer initially has to pay out of their pocket. Still, later these cannot be reimbursed too since it’s now under the clause of the medical insurance policy. It can also refer to cash, which is spent on deductibles and co-pays.

Out of Pocket Expense

What are Health Insurance Out-Of-Pocket Expenses?

Health insurance out of pocket expenses are the expenses that are not covered by the medical policy or the health insurer, and these costs need to be borne by the policyholder only. These can be various charges, which are as prescription fees, deductibles, co-payments, and coinsurance. There are also be certain expenses like ambulance charges, gloves, and other items that are not covered under the medical insurance policy. Thus, the policyholder must straightaway pay these sorts of expenses from their pocket, and the rest gets covered by the insurance company.

Examples of Out-Of-Pocket Expenses

  • Let us assume the case of medical insurance where we have deductibles, co-pays/co-insurance, and then out of pocket costs attached to the overall medical policy.
  • Let us assume we have a medical insurance policy where we have a maximum limit of $60,000. Now, the person holding the policy has incurred a medical expense of $40,000, which according to the medical policy, one may think that the insurance company should bear the entire expense, but that is not the case. It is where the out of pocket expense concept comes in. In this case, the insurance policy states that it has a $2,000 deductible and 20% co-insurance and a maximum of $8,000 out of the pocket expense.
  • Thus, when the policyholder has incurred a bill of $40,000 first, the deductible of $2,000 straightaway needs to be borne by him. Next comes the co-insurance part where 20% of the cost, so for the first $30,000 bill, the 20% charges come to be $6,000. Thus, adding the deductible and co-pay, which is $2,000+$6,000 = $8,000, we find the maximum out of pocket expense bracket has been reached, which was earlier stated as $8,000. Thus, the insurance company out of the entire $40,000 bill bears only $32,000, and the rest $8,000 is borne by the policyholder.

Advantages

There are several benefits which are as follows:

  • Such expenses can come into use under tax deductions like charitable donations, a medical expense that has not been reimbursed, etc. It can help in reducing the tax burden.
  • In medical insurance, the co-insurance part generally plays the role of a commitment of the policyholder towards the insurance. Generally, this is seen as collateral or down against the policy taken.
  • Out of pocket costs like taxes on cigarettes are used to change the nature of the behavior of consumers who smoke as this causes harmful health effects.
  • It brings about a sharing factor between two parties where both parties involved contribute to an expense.

Disadvantages

  • The cash required must be brought upfront, and at times there may be a lack of availability of cash, which will fail the overall transaction.
  • Even though the medical insurance company promises to cover the health-related cost, there is a catch behind it where the 100% cost will never be covered as the concept of out of pocket expenses pitches in.
  • Some expenses, like the tax on smoking, may not prove fruitful for all when it comes to human behavior as a person who is addicted to smoking will still smoke and instead pay more money for it.
  • They are not predictable and can, at times, disrupt the planning and budget of the individual concerned.

Difference Between Out of Pocket vs. Deductible

  • This concept will come when we take into consideration the medical insurance concept. Apart from the monthly or yearly premium which we pay for the medical insurance policy, the deductible is the amount one needs to pay from own pocket for the insurance covered before the actual medical cost gets borne by the health insurer. Thus, the amount which the medical insurance will pay to us will depend on two factors. First, whether the deductible has been paid or not and second, based on the coinsurance percentage; thus, a deductible is an amount one must pay before the insurance company helps the policyholder.
  • Out of pocket is the maximum amount of cost one needs to bear or pay for the medical care pertaining to the entire year. It includes deductibles, co-pays, and coinsurance up to a stipulated value or amount set by the insurance company. The premium, though, doesn’t fall under the out of pocket costs as that is the regular cost that one has to bear on a monthly or a yearly basis to maintain the medical insurance coverage. Typically, medical insurance policies with a low deductible and out of pocket expenses will come with a hefty premium.

Conclusion

Out of pocket expenses has both advantages and disadvantages. While some are reimbursed by the company or business, in cases of health insurance, these are strictly non-reimbursable. Typically, medical insurance policies with a low deductible and out of pocket expenses will come with a hefty premium. In business, it can be the employee’s spending which one has spent for business- or work-related purpose first out of his/her pocket, and then these get reimbursed by the company or business. At times these are also implemented to bring about changes in behavior, for instance, in the field of smoking as a tax on cigarettes, but then again, it depends on person to person on how he/she reacts to it.

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