Inpatient and Outpatient Benefits

Same-day surgery is an outpatient benefit.
Same-day surgery is an outpatient benefit.
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Sometimes a trip to the emergency room can result in a prolonged hospital stay. Treatment of serious injuries and illnesses can involve intensive diagnostic tests, blood transfusions and even surgery. After these treatments, some patients find themselves enduring months of rehabilitation services. When a service requires you to stay in the hospital for more than 24 hours, it is officially categorized as an inpatient benefit.

But not all trips to the doctor's office or even the hospital require you to bring a toothbrush and spend the night. Routine and emergency visits like an annual physical, a broken arm, a set of investigative tests and even some surgeries often take no longer than an afternoon. Any visit that is less than 24 hours is referred to as an outpatient benefit. Outpatients are not required to spend the night in the hospital and are able to come and go on the same day.

Hospitals and treatment facilities provide services for a broad range of conditions, so quite a few benefits fall into the category of inpatient services. In this article, we'll take a close look at the most common inpatient services covered by insurance plans and when these benefits actually kick in. We'll also learn about outpatient benefits, the fastest-growing segment of health care in the United States.

Most policies include a list of hospital services that are covered by a basic plan. These services include what you might expect: room and board for the duration of your stay, general nursing care and diagnostic exams. Generally, oxygen services, the administration of blood and plasma, and use of the operating room and the intensive care unit are covered. Inpatient benefits are the same whether you have an HMO plan or a fee-for-service plan, but in some cases preapproval is required. However, in emergency situations, preauthorization is usually waived.

As with any other benefit, most insurance carriers have specific guidelines for the payment of inpatient services. As mentioned above, most plans require preapproval and often a referral from your primary care physician for a medically necessary treatment. Once you're in the hospital, there is a limit to the number of days within a calendar year that your inpatient benefits will cover. Some plans even include a lifetime limit on inpatient treatment.

In addition to the basic services, most plans have a list of other types of covered inpatient services. To give you a better idea of what is covered when you're stuck in a hospital or other health care facility, we'll discuss the most common inpatient benefits.

Inpatient and Outpatient Benefit Types

Physical therapy is usually covered as an inpatient service.
Physical therapy is usually covered as an inpatient service.
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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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Sources

  • Children's Health Insurance Program. http://www.ibx.com/htdocs/custom/chip_manual/benefits_inpatient.html
  • Children's Health Insurance Program. http://www.ibx.com/htdocs/custom/chip_manual/benefits_inpatient.html
  • Medical Terms. http://www.medterms.com/script/main/art.asp?articlekey=39152
  • Montana Legislative Services. http://data.opi.mt.gov/bills/mca/33/22/33-22-705.htm
  • The Informatician. http://www.theinformatician.com/hci-glossary/vocabulary.html

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