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Outpatient vs. inpatient care

One easy way to save on care.

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.

Where to go: inpatient vs. 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.

Outpatient care 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.

Inpatient care, on the other hand, refers to care when you've been admitted to a hospital. Knee replacement surgery can also 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.

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Putting your benefits to work: what to expect

Outpatient care is usually lower in cost than inpatient care. Because some services, like knee replacement surgery, can be done in either an outpatient or inpatient facility, knowing how your benefits work and talking to your doctor about your treatment options can really benefit you.

Let's take a look.

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. That copay depends on where you go for care.

What to expect: Outpatient care falls on a lower 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 will likely have multiple copays for the care you receive. For example, you may have a copay for the services your doctor providers, plus the facility the procedure is completed in.

myWellmark®: your best bet for health insurance information

Know your coverage. Know your cost share. Knowing changes everything.



myWellmark makes it easy. Simply log in or register for myWellmark for all your health insurance information. Here you have access to personal plan detail and tools, including the myWellmark Care Finder.

With myWellmark's Care Finder, you can see an estimate of how much a procedure costs before you receive care. It uses your specific health plan benefits information, so you can:

  • See accurate, real-time out-of-pocket costs. This can help you plan ahead and have financial peace-of-mind before a doctor visit or procedure.
  • Search for in-network health care providers. You'll see a list of in-network providers closest to you. You can also compare costs. 
  • View patient reviews. Get the information necessary to make informed choices when choosing a provider, hospital/facility or specialist.

For BlueSimplicity members, there's the BlueSimplicity Estimator. This tool is specific to your personal benefits too, and even includes prescription drugs, so you know how much you'll have to pay the next time you need services or get a prescription filled.

Shop and compare for quality care. It's easy with myWellmark. Simply log in or register today!