Ambulatory benefits

What are ambulatory benefits?

Ambulatory benefits represent the insurance coverage of health care services provided while the patient is not staying in a hospital or other type of institution.

These benefits include emergency room care, home health care, outpatient care, physical therapy and pre-admission testing, and would apply after the patient meets certain conditions.

Deeper definition

To be eligible for ambulatory benefits, the insured must meet specific conditions that are certified by a doctor. These conditions could include intermittent nursing care or continued occupational treatment services.

To be covered, these services must be an effective and safe treatment, and specific to the patient’s condition. In addition, the time, frequency and duration of the medical services need to be complicated or involved enough that only qualified therapists or health care providers can carry them out effectively and safely.

Moreover, the insured is eligible if his or her condition is expected to improve in a predictable and reasonable time period, and requires a skilled therapist to help the person meet his or her treatment program.

Additionally, another element that a doctor must certify is whether the insured is homebound and Medicare certified, if the latter is the case. However, the insured is not eligible for ambulatory benefits if he or she needs more than intermittent or part-time skilled nursing care.

In a case where Medicare covers a patient for home health care, the home health agency should inform the patient of the amount that Medicare will pay. Other information that the insured should receive from the agency includes the services that Medicare does not cover and the amount the patient must pay out of pocket.

The Affordable Care Act also considers ambulatory benefits as part of essential health benefits, a set of 10 categories of services that health insurance plans must cover.

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Ambulatory benefits example

Robin is insured by CF Health Insurance Co. and is currently undergoing outpatient care from a physical therapist. For the insurance company to pay her costs, a doctor must confirm that her condition must be treated by a skilled therapist to help her meet her treatment program. Once that happens, Robin will receive ambulatory benefits from CF Health.

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