Is Transitional Care Management Only for Medicare Patients?

Transitional Care Management (TCM) was developed by the Centers for Medicare & Medicaid Services (CMS) mainly for adults older than 65. However, the model presented through its requirements and the CPT codes that CMS reimburses is also accessible to clinicians serving patients under 65. Additionally, many commercial payors cover transitional care through various products and arrangements, which we will explore.

TCM supports 30-day readmission reduction goals

CMS introduced TCM coverage in 2013 in response to the Hospital Readmissions Reduction Program (HRRP). As a Medicare value-based purchasing program, HRRP established procedure-specific readmission measures. These could reduce payments for conditions such as hip or knee replacements, acute myocardial infarction, COPD, and pneumonia if readmissions surpassed a set rate.

TCM is a bundled payment program concentrating on the 30-day hand-off period between a hospital or inpatient facility and a home or community setting. Through timely remote and in-person care, TCM strives to reduce readmissions, close care gaps, and support patients as they return home. 

TCM use for Medicare beneficiaries gaining traction

TCM adoption increased slowly but steadily by more than 300% from 2013 through 2019. 

Medicare beneficiaries receiving TCM services after discharge grew from 3.7% of eligible patients to 17.7% in 2019. The program has been effective. Recent research found that TCM participation reduced readmissions and decreased emergency department use and 90-day mortality.

Post-discharge analysis demonstrates that transitional care measurably impacts readmission rates, quality, cost, and patient outcomes. These benefits have been translated into numerous demonstration projects and models and have led to additional revenue.

Options for transitional care beyond Original Medicare

CMS established two CPT codes for TCM — 99495 and 99496. The difference in code and reimbursement rate relates to the level of medical decision-making complexity. As of 2025, 99495 pays $201.20 for moderate complexity, and 99496 pays $272.68 for high complexity, adjusted accordingly by the billing provider’s geographical location.

These active CPT codes are covered by Medicare and most commercial payors. However, the requirements and reimbursement rates can differ depending on the contract and insurance provider.

Original Medicare

TCM is covered under Medicare Part B with beneficiary cost-sharing. The 30-day TCM period begins when the patient is discharged from an inpatient or partial hospitalization setting and continues for the next 29 days. 

Medicare Advantage plans

Medicare Advantage plans, also known as Part C or MA plans, work with Medicare by providing most of Part A and Part B coverage, including TCM services. 

MA plans can benefit from TCM services as they support a new Star Rating measure under Transitions of Care (TRC) introduced in 2022. This measure requires a more significant role in preventing readmissions. 

Medicare for 18+ with qualifying conditions or disability

Adults under 65 may be eligible for Medicare TCM services if they have a qualifying disability or medical condition. Individuals receiving Social Security Disability Insurance (SSDI) payments for at least 24 months, plus a five-month waiting period, can qualify for Medicare coverage. 

Other individuals diagnosed with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) may also qualify for Medicare upon diagnosis without a waiting period.

These beneficiaries could qualify for TCM under Medicare if they meet the eligibility requirements, including moderate or high medical decision-making complexity. 

Medicaid, MCOs, dual-eligible

Research shows that Medicaid beneficiaries of all ages have readmission levels equal to those of older individuals covered by Medicare. One study found that one in five (21%) individuals with Medicaid experienced a readmission within 30 days compared with 6% of those commercially insured. 

State-sponsored Medicaid plans, as well as the managed care organizations (MCOs) some states contract with, may offer transitional care services. Some programs go beyond the initial 30 days to provide 60 or 90 days of transitional care and oversight.

Private commercial plans

Commercial plans may offer transitional care directly for adults under 65 as a care coordination service for high-risk beneficiaries. Some reimburse physicians based on the Medicare TCM model, providing a bundled payment for 30-day oversight, medication reconciliation, and timely coordinated care.

Parameters depend on the insurance product, contract terms, and the nature of the beneficiary cohort being covered. For example, Blue Cross Blue Shield of Michigan utilizes a health information exchange to send network providers admissions, discharges, and transfers. Clinicians can use this data to follow up with high-risk patients post-discharge from an inpatient stay.

Anthem launched a new TCM reimbursement policy in 2022 that covers services upon emergency room discharge. BCBS California provides TCM services for their special needs plan members when admitted to the hospital or discharged to a skilled nursing facility.  

Value-based care and Medicare shared savings

Because reducing readmissions has become a regulatory imperative, transitional care has become a focus for models used in value-based care arrangements, Medicare shared savings plans, and innovation demonstration initiatives.

While typically focused on Medicare beneficiaries, accountable care organizations implement transitional care programs to manage more complex patient discharges. 

Short-term demonstration programs, like the Multi-payer Advanced Primary Care Practice Demonstration, have covered transitional care for Medicare patients serviced by Federally Qualified Health Centers (FQHCs). 

Other specialized programs include Tricare’s transitional care for service-related conditions for active duty, Guard, and Reserve members.

Some hospitals and health systems implement their TCM programs, leveraging in-house primary care and home health capabilities. 

How ThoroughCare enables transitional care

Healthcare organizations use ThoroughCare to deliver integrated care management services to foster patient engagement and enhance revenue. 

Our platform provides health plans, health systems, and clinicians the digital infrastructure to deliver transitional care services, whether in compliance with Medicare’s TCM program or directly through other value-based or bundled payment contracts.

With seamless EHR integration and data interoperability across health information exchanges and remote devices, our platform supports solutions for:

• Chronic Care Management
• Remote Patient Monitoring
• Behavioral Health Integration 
• Annual Wellness Visits
• Transitional Care Management

Key questions answered

Is Transitional Care Management only for Medicare beneficiaries?

While CMS launched the TCM program focusing on original Medicare beneficiaries 65 and older, it has become a model used by Medicaid, commercial health plans, and health systems providing direct transitional care or reimbursing clinicians for the 30-day program.

Medicare beneficiaries also include adults 18 and older who have a qualified disability or conditions like end-stage renal disease or amyotrophic lateral sclerosis. 

Health plans and providers have developed various forms of TCM based on the Medicare model or innovation demonstration programs, including value-based care contracts, shared savings, accountable care, and other value-based arrangements.