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Inpatient and Outpatient Benefits


Inpatient and Outpatient Benefit Types
Physical therapy is usually covered as an inpatient service.
Physical therapy is usually covered as an inpatient service.
Keith Brofsky/Photodisc/Getty Images

Rehabilitation therapy includes occupational therapy, speech therapy and physical therapy. Any therapeutic exercise, massages, splits or braces, and prosthetic devices utilized during the course of rehabilitation therapy are usually covered by your policy's inpatient benefits.

Often, inpatient benefits will include measures to treat issues involving substance abuse and alcoholism. Services like individual and group­ counseling are usually incorporated, but treatment can also include detoxification and medication management. Usually in the case of substance abuse claims, treatment must happen at a medically monitored and managed residential facility. However, each insurance carrier has its own exceptions to this type of coverage, so it's best to check your policy. For example, many plans do not yet cover services like methadone maintenance for heroin addiction.

Mental health treatment is also covered by most plans that include inpatient benefits, but these benefits come with a number of exclusions. These exclusions are specific to chronic mental health conditions like forms of autism, sleep disorders and neuron-psychiatric disorders. Inpatient treatment for these types of conditions is usually not covered by most plans. Instead, most plans include coverage for individual, group and family therapy sessions, and medication management.

Obstetric care is also often included in the list of inpatient benefits. This can also consist of pre- and postnatal care, maternity care and the treatment of any complications during pregnancy and childbirth that could arise. Some plans have specific guidelines on the minimum and a maximum amount of time a new mother can stay in the hospital. For example, a mother who has a child by vaginal delivery usually stays for 48 hours while a mother who has a cesarean delivery usually stays for up to 96 hours. Inpatient care isn't the sole right of the new mother, though. Postnatal services, routine nursery care and preventative health care are included in most services. More extensive care -- like treatment of an infant's congenital defects, severe sickness and birth abnormalities -- is covered by most inpatient benefits for around 30 days.

Outpatient Benefits

Outpatient care, also known as ambulatory care, can include any diagnostic, treatment and rehabilitation therapies that do not require an overnight stay. It is the fastest-growing segment of health care in the United States. Because of advances in medical technology, many treatments that used to require lengthy spans of hospitalization are now happening on an outpatient basis.

All health insurance plans follow unique guidelines for determining the benefits allowed for outpatient procedures. With any HMO plan, your outpatient benefits are determined by what services are included in your network. Most HMO insurance plans also require preapproval, a referral from your primary care physician if applicable, and proof that the treatments are medically necessary. Outpatient benefits in a PPO or POS can be broader because you can go outside the network to find the right provider of the outpatient benefit you are seeking. Also, these types of plans normally do not require preapproval, although referrals may still be necessary.

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T­o learn more about inpatient and outpatient benefits, check out the links on the next page.

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