Have you ever had surgery and spent the night in the hospital? Or maybe you’ve driven a loved one home from a same-day procedure, like a colonoscopy. It’s important to know how these services may appear on your health insurance bill — because one is called inpatient care and the other is called outpatient care.
There can be quite a difference in what they cost and how your plan covers inpatient care vs outpatient care within the plan’s network of providers. The way to know the difference is whether you have to spend the night in a care setting (inpatient care) vs. being out the same day (outpatient care). Read on to learn about each type of care.
What is inpatient care?
Typically, inpatient care requires an overnight stay in a hospital or other care setting. Inpatient care tends to include more serious surgeries, procedures and care that require at least 1 overnight stay. Sometimes these visits are planned (like having a baby) and other times they’re not (like breaking a major bone). Inpatient care is needed for things like:
- Childbirth
- Heart attack or stroke
- Orthopedic surgery
- Respiratory failure
- Bone fracture
- Certain mental health conditions
- Long-term care (like nursing homes)
What is outpatient care?
Outpatient care is anything that can be done in your doctor’s office or other medical clinic within a single day. Outpatient care and procedures include things like:
- Exams or consultations (like your yearly wellness exam)
- Same-day surgeries (like hernia repair, gallbladder removal or cataract surgery)
- Some emergency care (like stitches or care for a broken finger)
- Certain tests (like a mammogram or colonoscopy)
- Imaging (like X-rays, MRIs and CT scans)
- Lab work (like blood tests and tissue samples)
How are costs different for inpatient vs. outpatient medical care?
Like all health care services, there are many factors that determine how much care will cost — whether or not it’s inpatient or outpatient is one of them. You may have guessed inpatient care is usually more expensive because you’re staying overnight in a hospital. Inpatient care includes costs for days spent in the hospital, each provider who treats you and every procedure you have. The longer you stay in a medical facility, the bigger the bill (even if your health plan helps out).
Many health plans cover certain outpatient care. For example, preventive exams and some screenings are covered at 100%. Other outpatient care, like lab work, imaging and minor surgeries may also be covered — but at your plan’s benefit level. Outpatient costs will almost always be lower than inpatient costs.
Are there different doctors and providers for inpatient and outpatient care?
Most doctors can treat you in either an inpatient or outpatient setting. That said, specialists, like surgeons, may be more likely to provide inpatient care. For example, if you need back surgery, a specialist (orthopedic surgeon) will perform that type of procedure — likely in an inpatient setting. Common outpatient care, like labs, imaging and certain cancer screenings may be done by technicians.
What’s the difference between inpatient and outpatient mental health care?
When it comes to mental health, there are a variety of treatment options. Depending on the level of care someone needs, their provider will recommend inpatient and/or outpatient mental health care.
The main difference between the two is time spent in therapy and level of support during treatment. For example, inpatient mental health care allows for greater access to services in one facility (like access to nurses, mental health professionals or nutritionists). This type of temporary around-the-clock care is usually meant to treat someone’s mental health condition and help them get back to safely living on their own.
Outpatient mental health care is more flexible for those who need less support to manage their mental health. The time spent in outpatient therapy can vary depending on the individual and type of treatment they seek. For those who choose talk therapy, they may see a mental health professional a few hours each week.
When does someone need inpatient mental health care?
Inpatient mental health care is recommended in cases of mental health or medical crisis, or if there isn’t much support at home. A provider will refer patients to this type of care if certain requirements are met during assessment. Conditions that may require inpatient mental health care include:
- Eating disorders
- Depression
- Psychotic disorders
- Self-harm
- Alcohol use disorder
- Thoughts of suicide
- Medically assisted detox from drugs or alcohol
Inpatient mental health care can include hospitalization or admission to a mental health facility where there’s access to medical evaluations, therapies and/or constant care.
When does someone need outpatient mental health care?
Outpatient mental health care may be a good fit for someone with a safe home environment who doesn’t need medical detox or 24-hour supervision during their treatment. This type of mental health care is more common than inpatient care. It can be sought out on an as-needed basis, unless otherwise recommended by a provider. Conditions that may require inpatient mental health care include:
- Anxiety
- Depression
- Mood disorders
- Trauma
- Alcohol use disorder
Outpatient mental health care may include different types of virtual or in-person therapy (like talk therapy) and/or medication. App-based mental health support is another option that has been gaining popularity.
Depending on your health plan, certain inpatient and outpatient mental health care may be covered. Always check your benefits to make sure you understand how your plan covers mental health services.
Choosing the right kind of care
It’s important to know which kind of care you need — and in which setting — so you can budget and minimize costs. Sometimes you may be able to choose whether you want inpatient or outpatient care, but other times you may not. If you find yourself planning for inpatient care, call your health plan to make sure you're choosing a network providerand doing all you can to keep out-of-pocket costs down.
Your primary care provider will help you navigate your care options so you can make an informed decision.
Find a doctor
Already a member?
Sign in or register on your plan website to see personalized benefit details and resources to help you manage your plan and health.
