TCM assists with your transition from a hospital or other medical facility back to your home. During the transition period, a healthcare provider will supervise and coordinate your care.
This service is particularly important for older adults with multiple chronic conditions or complex treatment regimens. Accordingly to a 2018 study, this type of care is associated with:
- fewer negative effects
- lower costs for care
- lower readmission rates
What does Medicare cover for transitional care?
Medicare will cover TCM when itâ€™s coordinated by a healthcare provider whoâ€™s approved by Medicare.
TCM services are covered under Medicare Part B (medical insurance). This is the part of Medicare the covers various outpatient services as well as some preventive care services.
Under Part B, youâ€™ll be responsible for paying these costs:
- Part B monthly premium. Your monthly premium is the amount that you pay every month for your Part B coverage. The standard Part B monthly premium for 2021 is $148.50.
- Part B deductible. A deductible is the amount you must pay out of pocket before Part B begins covering services like TCM. The Part B deductible for 2021 is $203.
- Coinsurance. Coinsurance is the portion of the cost you pay for covered services after youâ€™ve met your Part B deductible. For Part B, youâ€™re typically responsible for paying 20 percent of the Medicare-approved amount.
TCM involves a face-to-face visit with the provider whoâ€™s managing your transition within 2 weeks of your discharge. Theyâ€™ll also communicate with you at home via telephone or email during your transition period.
What if I have Medicare Advantage?
Medicare Advantage (Part C) is a health insurance option offered by private companies and approved by Medicare. A Medicare Advantage plan must offer the same basic level of coverage as original Medicare, which is made up of Part A and Part B.
Because of this, TCM is covered if you have a Medicare Advantage plan. These plans may also cover additional services you might use during your transition, such as transportation to outpatient appointments and meal deliveries.
Depending on your plan, Part C costs may differ from those of original Medicare. Additionally, many plans require the use of an in-network provider. Check that all of your providers are in network before setting up TCM services.
What services are included in transitional care coverage?
The overall goal of TCM is to work with you, your family, and other caregivers to help ensure a smooth transition back to your home. This can help both improve your quality of life and prevent unnecessary readmissions.
TCM coverage lasts for 30 days following discharge from a medical facility. During this time, the healthcare provider managing your transition will do the following:
- directly communicate with you or your caregiver within 2 business days of discharge, either in person, by telephone, or through email
- provide medical decision-making for situations with a moderate to high amount of complexity
- set up an in-person visit within 2 weeks of your return home, either at a doctorâ€™s office or another outpatient healthcare facility (or in some cases, in your home)
They may also offer other services during this 30-day period. These arenâ€™t typically provided in person, but can include things like:
- going over the types of care you received while you were in the medical facility
- verifying whether you may need any additional follow-ups or diagnostic tests
- working alongside your other healthcare providers to help better streamline your transition back home
- assisting with the management of the medications youâ€™re taking
- making referrals or arranging for medical appointments or other health- related services
- identifying any community resources that may be helpful to you
- providing you and your caregivers with additional information on ways to promote independence and your ability to perform daily activities
How do I qualify for coverage?
To qualify for TCM coverage through Medicare, you must first be enrolled in either original Medicare or a Medicare Advantage plan.
If youâ€™re already enrolled in Medicare, you must be current on your payments. Not paying your Medicare bills or premiums in a timely manner can cause you to lose your coverage.
When is TCM provided?
TCM can be provided to those with medical or psychological conditions that require decision-making of a moderate to high level of complexity.
For example, if you have multiple chronic health conditions, TCM may be used after a period of hospitalization. Another example is when youâ€™re first returning home after having a stroke.
TCM services are given when youâ€™re transitioning back home from specific types of medical facilities, such as:
- hospitals, including after inpatient care, partial hospitalization, or outpatient observation
- inpatient mental health facilities
- skilled nursing facilities
- inpatient rehabilitation facilities
- long-term care hospitals
The types of healthcare professionals who can provide TCM services are:
- physician assistants
- nurse practitioners
- clinical nurse specialists
- certified nurse midwives
TCM services last for only the 30 days following your discharge. Additionally, they must be given by a provider who accepts Medicare. To locate providers and facilities that accept Medicare, use Medicareâ€™s physician comparison tool.
Where can I find more help?
If you have additional questions or concerns about TCM, the resources below can help you to address them.
- Medicare. You can contact Medicare directly with specific questions by calling 800-633-4227 or by logging into your MyMedicare account.
- Your Medicare Advantage plan provider. If you have a Medicare Advantage plan and have specific questions about things like coverage or payments, contact your planâ€™s provider directly.
- Social Security. For questions about Medicare eligibility or enrollment, you can contact the Social Security Administration by calling 800-772-1213 or by visiting your local Social Security office.
- State Health Insurance Assistance Programs (SHIPs). SHIPs provide assistance and counseling to people with Medicare and can help answer questions you may have. Search for your stateâ€™s SHIP here.
- Medicaid. Medicaid helps those with low income and resources pay for healthcare-related costs. The eligibility requirements and services covered vary by state. Find your state Medicaid agency here.
TCM helps streamline your transition from a medical facility back to your home. These services are offered by a healthcare provider in the 30 days following your discharge.
Some of the services provided with TCM include an in-person visit, medication management, scheduling follow-up visits, coordinating with your other healthcare providers, and more.
Medicare Part B covers TCM services. Theyâ€™re also covered if you have a Medicare Advantage (Part C) plan. The exact costs of TCM can depend on what type of Medicare coverage you have.
If you have questions about TCM and Medicare, donâ€™t hesitate to reach out to Medicare or your planâ€™s provider directly. You can also use resources like your stateâ€™s SHIP or Medicaid office to get more help.
Medicare plan options and costs are subject to change each year.
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