Transitional care management services

Medicare Coverage Information

Overview

Medicare provides transitional care management services to help patients safely move from hospital or inpatient settings back to their home or community. These services ensure proper follow-up care, medication management, and coordination between healthcare providers to prevent readmissions.

  • Covers comprehensive care coordination after hospital discharge
  • Includes communication with patient and healthcare providers
  • Helps manage medications and follow-up appointments
  • Aims to reduce hospital readmissions
  • Typically covers services within 30 days of discharge
  • Medicare Part B beneficiaries
  • Patients discharged from hospital, skilled nursing facility, or certain inpatient settings
  • Patients with complex medical conditions requiring care coordination
  • Covered under Medicare Part B
  • Beneficiaries may be responsible for 20% coinsurance
  • Part B deductible may apply
  • Actual out-of-pocket costs can vary by specific Medicare plan
  • Must be ordered by a physician or qualified healthcare provider
  • Services must be medically necessary
  • Limited to specific time frame after hospital discharge
  • Not all patients or discharge situations qualify
  • Discuss transitional care needs with your healthcare provider
  • Confirm coverage details with your specific Medicare plan
  • Request a comprehensive discharge plan from hospital staff
  • Call 1-800-MEDICARE for specific coverage questions
Last updated: 6/15/2025

Quick Information

Provider
Medicare
Last Updated
6/15/2025
Topics
Medicaretransitional care managementhospital dischargemedical care transitionpost-hospital care

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