Kids and Health Care: Outpatient and Inpatient Coverages
When you're using medical services, remember that most insurance plans make a distinction between inpatient (someone who's been admitted to a hospital for at least 24 hours) coverage and outpatient (someone who plans to go home within a few hours of any treatment or procedure) coverage. This distinction can definitely affect which claims are paid.
If you have coverage for outpatient services under your plan, the plan will usually pay for 80 percent of covered outpatient services and supplies, subject to the maximum benefit amount. You must pay the other 20 percent of the charges or copayment.
Here's a list of outpatient services and supplies that health plans typically cover:
- x-ray and fluoroscopic examinations;
- radium and other radioactive substance;
- electrocardiograms, microscopic and laboratory tests;
- drugs/medicines that may be purchased only on the attending physician's written prescription and that are dispensed by a licensed pharmacist;
- casts, splints, braces, crutches and artificial limbs; and
- oxygen and equipment used for its administration.
Outpatient services are covered only when rendered due to injury or sickness, while coverage is in force for an insured, and as the direction of a physician or surgeon. Outpatient benefits do not include benefits for the services of a radiologist, pathologist, anesthesiologist, physician or surgeon.
Hospital inpatient care provides you with benefits for charges a hospital makes on its own behalf (i.e., room and board, nursing care, etc.). Most plans limit room and board to a semi-private room rate, a maximum dollar amount per day and a maximum number of days. Miscellaneous services are also limited to a maximum dollar amount.
Say you have inpatient coverage with benefits of $300 a day for a maximum of 365 days. Your son is confined for 10 days in a private room. The hospital charges $325 a day for a private room and only $250 a day for a semi-private room. Your policy will only pay $2,500 -- the semi-private room rate for 10 days. You end up paying the difference.
Inpatient benefits can provide coverage for confinement for mental, emotional or nervous disorders, alcoholism and drug dependency -- but usually not for more than 30 days in any one policy year.
