Medicare Part B covers transitional care management. This service usually lasts for 30 days after a person has returned home from a hospital or qualifying care facility.
Transitional care is a healthcare service that ensures a person receives the care they need after they leave a hospital or a specific type of healthcare facility.
This continuing care offers a smooth, organized transfer from the hospital or healthcare facility to a person’s home.
Transitional care may prevent readmission which can reduce healthcare costs.
This article will look at transitional care, coverage under Medicare, and extra help with costs that may be available.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Part B covers outpatient services, including transitional care.
A person may need to pay the Part B deductible, which in 2020 is $198.
A coinsurance of 20% may also apply to eligible costs.
Transitional care management (TCM) services involve looking at the adaptations that a person may need when moving from a hospital or inpatient facility back to their home.
Specifically, transitional care looks to manage the period between an inpatient stay and a return to a community setting. A primary care physician usually oversees transitional care.
TCM usually involves the transfer of care to a person’s community or home, from:
A healthcare provider overseeing TCM will work with a person to manage their care for the first 30 days after they return home, working alongside another caregiver or other physicians as needed.
A healthcare provider may also:
- review medical information concerning the care the person received while they were an inpatient
- provide information to help a person transition back to home life
- work with other care providers
- assist with physician referrals or make arrangements for follow-up care
- assist with managing and scheduling medications
- provide information about health and community resources
- provide education to a person, family member or caregiver to support independent living
- review the requirements for additional tests or treatments
- follow up on the results
The following healthcare professionals may provide TCM services:
- physicians (any specialty)
- certified nurse-midwives
- clinical nurse specialists
- nurse practitioners
- physician assistants
A non-physician can provide TCM services, provided their state has legally authorized them.
TCM begins on the date a person is discharged from an inpatient setting and continues for the following 29 days.
During the 30 days, the authorized healthcare provider must provide the following services:
- Contact: The healthcare provider should contact the person receiving health services or the caregiver within two business days after discharge. Contact may be by phone, email, or in person.
- Supply certain non-face-to-face services: The healthcare provider must provide services they feel are medically necessary for the person’s recovery. Clinical staff may also provide these services under the direction of a doctor.
- An in-person visit: Depending on an individual’s medical condition, the healthcare provider should carry out one face-to-face visit within 7–14 days of the discharge date.
Although face-to-face visits may typically take place in a doctor’s office, it may also be in a person’s home. As of January 1, 2014, a healthcare provider may also use a qualified telehealth service in place of the face-to-face visit.
There are a few ways to receive financial help for transitional care costs, including programs available in the state or county a person resides.
Medicaid is a financial assistance program consisting of a partnership between the state and federal governments. For some individuals with limited income, Medicaid may help with transitional care costs.
Medicare Savings Programs
Medicare savings programs (MSPs) may help with costs associated with transitional care services, such as coinsurance, copayments, deductibles, and prescribed medication costs.
The Program of All-inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that may help older adults meet their healthcare needs from within the community.
Extra Help Program
Extra Help is a program that helps individuals with limited income and resources to pay their Medicare Part D prescription drug costs, such as premiums, deductibles, and coinsurance.
Private insurance companies administer Part D plans, and a person can contact their plan provider to verify the level of Extra Help for which they qualify.
TCM is a service that becomes available after a hospital or medical facility has confirmed that a person is ready to be sent home. The care lasts for 30 days, beginning the date of discharge.
TCM involves a healthcare professional making sure a person adapts to returning home and has appropriate follow-up care. The process is often managed by a family physician.
Medicare Part B covers TCM, and out-of-pocket costs may apply.
Programs that may provide financial assistance for transitional care costs include Medicaid, Medicare savings programs, PACE, and Extra Help.