If you’re a health care company, Medicare is probably one of your biggest customers. You know that every year the government changes how they reimburse for services – and this time, they are changing it up again with TCM! But what does TCM really mean? Read on to find out more about this new reimbursement program.
What is Transitional Care Management (TCM) in Medicare?
TCM is a voluntary, Medicare-approved alternative to inpatient care when an individual has been recently discharged from a hospital or skilled nursing facility. A TCM plan details how the patient will be managed at home before returning to usual self-management.
The services provided under a TCM management plan should include:
- Personalized assessment of the patient’s health and functional status
- Assessment of the patient’s ability to function at home without assistance and develop a plan for managing any identified risks.
This TCM program offers post-hospitalization support in areas such as:
- Medication management(reduce chances that patients miss, forget or stop taking their medications after a hospital stay)
- Skilled nursing care (reduce chances that patients need readmission to the hospital; Medicare covers skilled services, such as wound care and postoperative management when provided by certified professionals)
- Assessment of any mental health or behavioral needs (coordination with mental health professionals or other providers)
- Communication among healthcare providers (to ensure that a patient’s care plan is followed and to help avoid duplication of services, which results in more cost-effective care)
Are There Different Levels of TCM?
Yes. This program is available to all Medicare beneficiaries who are at risk for hospital readmission or who are living at home and facing barriers to self-management.
The level of care provided depends on the patient’s needs and is determined by an assessment that includes:
- The patient’s health status and functional abilities (vital signs, mental status, mobility, and medical history)
- Social, familial and environmental factors affecting the patient’s ability to function at home
What Benefits Does Medicare Provide Under TCM?
Medicare Part A pays for services covered under a TCM plan up to 100 days after discharge from the hospital or skilled nursing facility. This includes care coordination with other providers, inpatient psychiatric services, medications, and medical supplies and equipment.
Once TCM ends, the patient has a 60-day transition period before standard Medicare coverage begins again. The transition period is intended to keep patients from going directly from being hospitalized or living in an institution back to their own homes without any support. After this time, the patient will have supplemental insurance that should pick up most of the tab for any hospital or skilled nursing services.
If Part A benefits have been determined to be medically necessary, Medicare will continue to pay for covered services, including medications and medical supplies, after the 100-day coverage period ends under TCM. However, specific requirements must be met in order for this continued payment to occur (e.g., regular contact with the patient’s physician; a signed transition plan outlining efforts that will be made to help the patient return home and qualify for Part C coverage). The transition period also continues during this time.
Can Anyone Be Admitted to a Nursing Facility Under TCM?
No. In order to get admitted to a nursing facility, the Centers for Medicare & Medicaid Services (CMS) requires that a patient’s health status and functional abilities be reassessed within 10 calendar days of admission to the facility. This readmission to the hospital or skilled nursing facility happens when it is determined that the patient needs more intensive services than originally expected.
After this assessment, patients may request Part C coverage and receive home health or hospice care. This is known as the “Part C to Part A” transition period (see Health Insurance Coverage for more information).
Can a Patient Under TCM Be Admit to a Hospital?
Yes. However, admission will not be approved if it’s determined that this is medically unnecessary. The patient’s physician must determine that:
- The patient needs a hospital stay that is longer than what’s covered under Part A
- There aren’t other providers available to provide the needed services (e.g., palliative care)
If these requirements are met, Medicare will pay for 100 days of inpatient hospital services provided by an acute care hospital. In this case, Medicare will cover the costs of inpatient psychiatric or rehabilitation services and medications after 30 days. (NOTE: If a patient is transferred to another hospital during this time, it’s counted as one of the 100 days.)
What Are Services Not Covered Under TCM?
Patients who are transferred to a different healthcare setting and continue to meet the program’s eligibility requirements may be eligible for TCM coverage. However, they must still qualify for Part B (or have disability insurance or end-stage renal disease supplemental insurance) in order to receive these benefits.
- Costs incurred by a facility other than an acute care hospital (e.g., a skilled nursing facility).
- Hospice care, home health, or any other type of non-acute care services.
- Costs incurred by out-of-network providers.
What is the 90 Percent Rule?
Under TCM guidelines, if the beneficiary’s expenditures for covered services are more than 90 percent of the total Medicare-approved costs for their care in a calendar year, there is an assumption that the beneficiary will have difficulty covering these remaining costs (as well as their future expenses). Should this occur, beneficiaries can enroll in Part C and receive services from a private health plan.
When Can Someone Apply to Part C?
Most people are automatically transferred to Part C after the 100-day coverage period ends under TCM. However, patients who have designated a proxy or representative payee and those who meet specific other eligibility requirements may qualify for an extended transition period, which can last up to eight months. If this is the case, you’ll be informed of your rights and responsibilities as a beneficiary under the Part C program.
When it comes to Medicare, there is a lot of confusion. TCM is a strategy that can help you better manage your health care costs by coordinating and managing your medical needs to reduce hospitalizations, emergency room visits, and re-hospitalizations.Hope this article could answer questions likeWhy Patient Engagement Is Important In Healthcare.
