This article was last updated on April 30, 2021.
You've been dealing with knee pain for months. After a few appointments with your doctor, you decide it's time to have that knee replacement surgery you knew was eventually in your future. The next big decision: Where should you have the procedure done? Where you go can make a big difference on your wallet.
How to decide on inpatient or outpatient care
You've probably seen the terms inpatient and outpatient care in your benefits documents, but what is the difference? Both refer to the way your service is provided. Here's the rundown.
- Inpatient care refers to care when you've been admitted to a hospital. Knee replacement surgery can be done in an inpatient setting, along with other treatments like having a baby or heart surgery. Inpatient care requires one or more overnight stays.
- Outpatient care, on the other hand, doesn't require an overnight stay at a hospital. Along with knee replacement surgery, services typically handled in an outpatient setting are things like a tonsillectomy or putting tubes in your kid's ears.
Take a look at the graphic below to demonstrate how knowing the difference between inpatient and outpatient care can save you time and money.
Know the difference between inpatient and outpatient care. Your time and money is at stake!
Meet Joe. He likes to stay active. But recently, he has been in pain because of a bum knee. Not the type to let life pass him by, he made an appointment with his personal doctor. It turns out, Joe needs a knee replacement.
Joe must decide where he will go for care.
- If he's in an inpatient setting at the hospital, he'll recover overnight in an uncomfortable hospital bed, have time away from home, and pay more money out-of-pocket. The average inpatient total cost of care for a knee replacement is $17,115.
- If Joe is treated as an outpatient at a surgery center, he'll recover in his favorite chair at home, be able to spend more time with his dog and have more money to spend on getting active again. The average outpatient total cost of care for a knee replacement is $13,216.
Of course, not all procedures can be done in both an inpatient and outpatient setting, so talk to your doctor and understand your benefits. Get started by logging in or registering for myWellmark® Opens New Window.
Joe's experience is just one example. But, by simply knowing some basic health insurance terms, better understanding his benefits, and talking to his doctor about his options, he can make an informed decision.
How the type of health plan can affect out-of-pocket costs
Outpatient care is usually lower in cost than inpatient care. Because some services, like knee replacement surgery, can be done in either an inpatient or outpatient facility, knowing how your benefits work and talking to your doctor about your treatment options can really benefit you.
Traditional copay plan
How your cost share works: You pay a set amount each time you go to the doctor's office. For treatment outside the office, like inpatient and outpatient care, you often have to meet your deductible and pay a percentage of the total cost.
What to expect: Because how much you have to pay depends on the total cost, choosing care that is less costly from the start helps your bottom line.
Traditional coinsurance plan
How your cost share works: For some office visits, you still have a set amount you have to pay. But for specialized office visits, you may have to pay a percentage of the total cost. Same goes for services outside the office, like inpatient and outpatient care. In these instances, you may have to meet your deductible as well before paying a portion of the total cost.
What to expect: Similar to a traditional copay plan, your cost share depends on the total cost of care. So, if an outpatient facility costs less than care done in an inpatient setting, you also pay less.
High-deductible health plan
How your cost share works: You pay the full cost of care until you reach your deductible. Assuming your deductible and out-of-pocket maximum (OPM) match, once you reach your deductible, Wellmark pays 100 percent of all covered services.
If your deductible and OPM aren't equal, you may have to pay a portion of the total cost for services until you reach your OPM.
What to expect: If you haven't met your deductible yet, you pay the full cost of care. That means you will likely pay less when getting care at an outpatient facility than being admitted to the hospital.
How your cost share works: With no deductible or coinsurance, you only have a single copay, and you know it up front. A copay is a fixed amount that you may have to pay out-of-pocket when incurring medical expenses. That copay depends on where you go for care.
What to expect: Outpatient care falls on a lower copay level than inpatient care. That means, you pay less. You typically pay more for inpatient care, but it's also all-inclusive. This means you have one single copay for all your care.
With an outpatient facility, you'll also have one copay. However, you may be charged another copay if imaging is required during your outpatient visit.
myWellmark®: it makes health insurance easier
No matter if you're at home or on-the-go, you have tools, resources and insights to help you manage health care spending and live a healthier life. By simply logging in to myWellmark Opens New Window, you can estimate your cost of care for services before you go, track and organize your family's medical expenses, plus much more.
To make sure you get the most from your health insurance benefits, log in or register today!
1 Amount is based on the average allowed cost for inpatient and outpatient care, including full and partial knee replacements. Your out-of-pocket costs will depend on your plan benefits.