Case Management Center
Utilization Management: Levels of Care
Patients receive health care in a number of different settings in today's managed care environment. This typically is based on what they need and what their insurance will cover. Insurers have different criteria for determining the setting or "level of care" that is required. The criteria most often are centered around the patient's condition, severity of illness, and intensity of care that is needed. At Boston Children's Hospital, the utilization management case managers play a key role in getting services approved at the appropriate level of care as defined by individual insurance policies. They provide information from the medical record and from communications with the multidisciplinary team to justify the medical necessity of patient care to insurers.
Please note: Coverage for health care services varies widely based on the type of insurer and coverage/conditions of individual policies. Patients and their families should familiarize themselves with the specifics of their insurance coverage to be sure they understand the rules they must follow and what their financial obligations for care may be.
The discharge planning case managers play a key role in ensuring that patients are moved safely and appropriately from one level of care to another. For example, they are responsible for helping to identify appropriate post-hospital care facilities, facilitate transfer arrangements and insurance approvals, and to complete referrals for home care services. They also work closely with patients and their families to evaluate needs and expectations and to make necessary arrangements for transition from one level of care to another.
The following are the main settings/levels of care that patients of Children's Hospital may need.
Doctor's Office or Hospital Clinic:
- This is the typical setting for outpatient care or ambulatory services.
- Patients make appointments for office visits with doctors, specialists, nurse practitioners, physician assistants, or other members of the clinical team.
- During visits, patients may have physical exams, testing, or procedures.
- Most often, patients go home after their visits.
- Many patients will have copays for office visits based on their insurance policies.
- Some patients will be required to get approval from their primary care doctors to be seen at specialty clinics or to have procedures/tests, e.g., those with HMO or POS insurance policies.
Emergency Department Care:
- This is where patients go when they need emergency care that cannot wait for a scheduled outpatient visit. This includes sudden changes in health care conditions, life-threatening circumstances, and trauma.
- The first priority of any ED is to care for those who have true emergencies.
- Emergency Departments (EDs) are required to have systems in place to take care of people who come in with minor or urgent health care issues, especially during the evening and night when primary care doctors' offices are closed. This can lead to ED overcrowding and long waits.
- Most patients will be discharged from the ED setting; however, others may require admission to another level of care.
- Some insurances will require approval from the primary care physician for coverage of ED services, especially when the circumstances are not true emergencies.
- Some patients will have copays for ED visits that may or may not be waived if the patient is admitted to the hospital.
- Patients require "observation care" when they need care or monitoring for a longer period of time than typically can be provided in an office or ED setting. Examples include conditions that have not responded to at least four hours of ED treatment and extended recovery from ambulatory procedures or surgery.
- In most cases, patients are admitted to observation care when it is reasonable to expect that care will not exceed 24 hours. There are exceptions to this rule, based on insurance policies.
- At Boston Children's Hospital, patients may receive observation care in a number of settings, including the ED, recovery units, and hospital beds.
- Patients/families may have copays or out-of-pocket expenses for observation care. Some insurances require that families meet certain deductibles before observation care is covered; others may be subject to copays of a percentage of contracted charges.
Acute Hospital Care:
- Patients are admitted to the hospital on an emergency or urgent basis when they have illnesses, injuries, or conditions that cannot be handled in a timely and appropriate way in an outpatient setting and/or that have not responded to outpatient therapy. Most insurance policies will have some coverage for emergency hospital care.
- Patients are also admitted to the hospital on an elective basis for scheduled procedures and surgeries that require inpatient care; elective admissions are also approved for further evaluation and management of complex or undiagnosed conditions. Elective admissions typically require prior authorization from insurance companies.
- There are several of levels of care within the hospital including intensive care, intermediate care, and acute care. Patients are assigned to these levels based on the severity of their condition, the intensity of services that they require, and the availability of appropriate clinicians to meet their needs.
- Discharge from the hospital is based on clinical stability, arrangements for post-hospital care, approval of the attending physician, and agreement by the patient/family with discharge plans.
- Many patients will have financial costs associated with hospitalization as dictated by their insurance coverage. Some will have to meet out-of-pocket deductibles or copays before hospital charges will be paid by the insurer.
Acute Rehabilitation Hospital:
- Some patients will need transfer to an acute rehabilitation hospital after care at Children's Hospital to continue their recovery and receive comprehensive therapy services.
- Patients who will qualify for acute rehabilitation must be clinically stable, require specialized therapeutic skills and/or equipment, and be able to tolerate at least three hours/day of therapy five days/week; they also must require evaluation and management of a medical practitioner at least three times/week.
- Length of stay at acute rehabilitation hospitals varies based on condition and patient progress.
- Many patients will have financial costs associated with their rehabilitation stays as dictated by their insurer.
- Insurance companies need to give approval prior to transfer to this level of care.
- Some insurance will only pay for a certain number of days/year for acute rehabilitation services.
Subacute Rehabilitation & Skilled Nursing Facilities:
- Patients who will qualify for subacute rehabilitation must have continued medical and therapy needs that cannot be safely and/or appropriately met at home. They need at least four hours/day of skilled nursing care, medical evaluation and management at least twice/week, and must be able to tolerate 2-3 hours/day of therapy five days/week.
- Patients who will qualify for skilled nursing facility care must meet a lower level of care requirements, e.g., skilled nursing at least daily, ability to tolerate 1-2 hours/day of therapy five days/week, and medical evaluation and management at least once/week.
- Length of stay at either of these levels varies based on the patient's condition and progress to goals.
- Many patients will have financial copays or out-of-pocket expenses associated with these levels of care.
- Insurance companies need to give approval prior to transfer to either subacute rehabilitation or skilled nursing facilities.
- Some insurance companies will limit the number of days/year for which they will pay.
Nursing Home Care:
- Long term nursing homes are for patients whose needs can no longer be met in their homes. This level of care is sometimes called custodial care.
- There are limited facilities that provide this level of care for children. Adult patients will have more options.
- Most insurances will not pay for this level of care; Medicaid policies may provide coverage.
- In Massachusetts, patients/families and care providers are required to meet certain state regulatory requirements before placing a child in a nursing home for care. The Medical Review Team (MRT) of the Department of Public Health is the regulatory body that oversees this process.
Skilled Home Care:
- Some patients require skilled assessment and services after discharge from an ED, hospital, or post-acute hospital. Such services may include skilled nursing and/or visits by PT/OT/SLP, behavioral health, social work, infusion therapy, and home respiratory care.
- Most insurers will cover skilled home care services ordered by a medical practitioner for patients/caregivers whose home environment is safe and appropriate for continued care, who are willing to learn and participate in care needs, and who is functionally homebound.
- The homebound status is met when it would require a taxing effort to leave the home as a result of the patient's mobility and equipment issues.
- Some patients will have out-of-pocket expenses related to home care services, based on their individual insurance policies. Typically, home care providers will call insurance prior to rendering services to get approvals and to be able to advise patients/families or their financial obligations.
- This level of care is available for patients who are near the end of life.
- Hospice care can include nursing care, pain control, spiritual and emotional counseling, equipment, and symptom management. Sometimes if can be done in the home or in a palliative care facility. In the home setting, family and/or friends are the primary caregivers.
- Insurances have differing criteria and coverage for hospice care.
- This level of care provides family members/caregivers to take a break from the care of their loved one at home.
- Respite care can be done in the home or in a nursing facility.
- There are few insurances that will cover respite care; patients/families may have to private pay for these services if there are not public or grant funds for which they may be eligible.