Inpatient vs. Outpatient Insurance: What’s the Difference?

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No matter what your insurance status is, chances are you have come across the terms “inpatient” and “outpatient” when you are looking for health insurance. It is important to understand the differences between the two major benefits for better management of your healthcare and health insurance.

What is inpatient vs. outpatient care? What are inpatient and outpatient insurance?

Simply put, inpatient insurance covers treatments that require hospitalization, whereas outpatient insurance covers any medical care that does not require hospital admission, thus alternatively called “ambulatory care”.

You can expect that inpatient care generally involves more serious conditions, major surgeries, severe injuries and sometimes childbirth which require overnight monitoring in a hospital. Meanwhile, outpatient care encompasses a wide array of services, namely doctor consultations, health check-ups, diagnostic tests, minor surgeries and procedures, many of which are also available outside a hospital setting, i.e. in clinics or healthcare centers. For patients in the emergency department or patients with an observation status — that is, further observation is needed to determine the level of care necessary — they are considered as outpatients before being formally admitted to the hospital.

When choosing your insurance plan, be sure to read through the policy carefully or consult your advisor to understand your insurer’s definitions.

How Alea can help you save on insurance

What is inpatient insurance?

Inpatient benefits are essential benefits of an insurance plan, they protect you from paying out-of-pocket when you need hospital care.

Inpatient coverage in Hong Kong typically include:

• Private hospital room fees
• Intensive care room fees
• Medications
• Surgery
• Doctor / Specialist doctor consultation fees
• Anesthetist and operating theater costs
• Diagnostic tests and imaging (e.g. X-rays, CT scans, MRI scans, laboratory tests)
• Rehabilitation

*Cosmetic treatments or any elective procedures that are not deemed medically necessary are generally excluded.

Medical expense for inpatient care increases substantially with the duration of your stay, the level of treatment delivered and the type of room chosen. The degree of coverage may vary among insurers, some plans may not fully cover surgical costs and require you to pay out-of-pocket for any amount that exceeds the sub-limits.

Note that in private hospitals, the costs can vary greatly depending on the room type you choose (i.e. private, semi-private or ward level), the more expensive your room type is, the more expensive the other expenses would be. Many companies opt for semi-private level inpatient coverage for their employee health benefits.

What is outpatient insurance?

Sometimes referred to as “clinical benefits”, outpatient coverage in Hong Kong typically includes:

• Doctor / Specialist doctor consultation fees
• Diagnostic tests (e.g. X-rays, CT scans, MRI scans, laboratory tests)
• Medicines
• Vaccinations
• Health check-ups
• Rehabilitation treatments

*Cosmetic treatments or any elective procedures that are not deemed medically necessary are generally excluded.

*Alternative therapies, e.g. Traditional Chinese medicine, acupuncture, chiropractic, osteopathy, may or may not be covered, depending on the insurer’s policy.

Outpatient care usually costs less than inpatient care as most of the time, it only involves medications, treatments and the doctor’s fees. Having sufficient outpatient coverage for private services saves you time queuing for services in the public sector.

What is day-patient insurance?

As medicine evolves, so have day-patient surgery cases. More and more hospital procedures and surgeries can be done on a day-case basis — the patient is admitted to the hospital for a few hours for a minor procedure, shortly after which the patient can return home with prescribed medications and dressings.

Such arrangements can save overnight room fees at the hospital and give you the comfort to recover at home.

Many insurance providers in Hong Kong and internationally have developed day-patient benefits. Most day-patient benefits are embedded under hospital benefits and most often require, just like for inpatient care, the insurer’s pre-authorization and/or a Guarantee of Payment (GOP).

Talk to an Alea advisor to find out your options.