If you’ve ever watched a professional sport live on TV, then you’ve probably seen a major debate break out about the distinction between “in” and “out” of bounds. The game could be baseball, football, or even tennis; in any case, entire matches can be won or lost based on whether a ball is “in” the field of play, or whether it crossed a line and went “out.”
And the big game isn’t the only time when this distinction is vitally important. “In” and “out” also make a big difference when it comes to medical treatments—and how your insurance plan may help you to pay for them.
If you’ve spent any time researching health insurance plans, or received a hospital bill and tried to break down your costs, then you understand the crucial distinction between “inpatient” and “outpatient” care. But what do these two important terms really mean? How do they impact your level of care, and why might your insurance policy cover inpatient and outpatient services differently?
Let’s break it down.
The Big Difference Between Inpatient and Outpatient Care
The most important distinction between inpatient and outpatient care is all about time.
Your visit to a hospital or medical facility generally qualifies as inpatient if you are formally admitted by a doctor for a full day or more. Hospitals tend to measure timing in terms of “midnights,” or overnight stays. The more nights you spend in the hospital, the lengthier your inpatient stay, and the more you get billed.
Outpatient care, in contrast, is a medical service that only takes a few hours, allowing the patient to leave shortly after their procedure is finished. Outpatients do not need to be formally admitted, or stick around for lots of additional monitoring, testing, or rehabilitation. Once their treatment is completed, they are free to go home. Sometimes you may be held at a hospital and designated “under observation” for a few additional hours. But in most cases, this will still count as outpatient care, provided you are not admitted to the facility for additional time after your evaluation.
The rule of thumb is this: If you stay in a facility for more than 24 hours, including an overnight stay, your treatment is most likely going to be considered inpatient. It is considered outpatient care if you are released by the medical team or doctor after just a matter of hours, and do not need to spend a night in the hospital, clinic, or doctor’s office.
Understanding Inpatient Care
Inpatient care may include a number of procedures and services. Most commonly, services that fall under the inpatient category include:
- Major surgeries requiring monitoring and recovery time
- Complicated medical issues requiring significant testing and observation
- Admission to a long-term substance abuse rehabilitation center or a psychiatric facility
- Admission to a skilled nursing facility or physical rehabilitation facility
When you receive inpatient treatment, medical staff will typically be on hand and working with you for the entire length of your stay.
Depending on your insurance coverage, you may have time limits on certain types of inpatient care. For example, inpatient stays at a behavioral health clinic, skilled nursing facility, or substance abuse treatment center may be limited to 31 days in a calendar year. Other plans may limit how long you can receive covered inpatient care after childbirth, or following major surgery.
Understanding Outpatient Care
Outpatient services are generally more routine treatments. Some common types of outpatient care include:
- Doctor’s visits, including routine checkups and specialist visits
- Tests, lab work, and X-rays
- Minor surgeries without complications
- Emergency room services (if you are not admitted for an additional stay)
- Physical therapy and chiropractic care
- Speech and occupational therapy
- Behavioral health visits
In many cases, patients often prefer to receive outpatient care if given the option. Being allowed to rest and recover in the comfort of home often makes things more convenient and more comfortable. Outpatient services are also, typically, significantly less expensive than inpatient services, regardless of your level of insurance coverage.
The Role Health Insurance Plays in Inpatient and Outpatient Care
Understanding the distinction between inpatient and outpatient service is important when it comes to your health insurance. Some plans make distinctions between coverage for inpatient and outpatient care, such as placing limits on the amount of inpatient care someone can receive in a year.
While every policy is different, it is generally true that inpatient services are going to be more expensive, even with your insurance plan helping to share costs. Because of the high level of supervision and attention you’ll likely be receiving with inpatient care, the costs of treatment will be higher. And copayments and coinsurance on inpatient services are going to depend on the length of your stay; the longer you are admitted, the more expensive it will be.
The bright side? With insurance, you’ll really only be paying a fraction of the total costs for both inpatient and outpatient services, making all sorts of medical treatments far more affordable and easier to receive than they would be otherwise.
Reaching Out for Help
The health insurance industry is always changing, and it can be hard to know where to go for reliable answers to your most important questions. That’s where Matt Peebles and the Enrollment Specialists would love to step in and help.
Matt, our founder and principal consultant, is one of the leading health insurance brokers in the country for a reason: he loves this stuff. Matt is a people person with a true passion for crafting insurance solutions that really work for his clients. He understands all of the ins and outs of healthcare, so that families and businesses all around the country can get the insurance they need, confident that their costs will always be minimized, while their coverage is at its peak.
Even better? Once you’ve worked with the Enrollment Specialists, Matt will always be just a quick phone call or email away, whenever you have a question or concern, for the entire life of your policy. There’s no question too big or small for this health insurance superhero. He’ll always be ready to help, whenever you need clarification about your policy, or want an advocate to work with your insurance carrier on your behalf.
Have any more questions about inpatient and outpatient care? Ready to get started finding better coverage for yourself or your small business? Drop us a line today to get the conversation started.