Managing your care at home after an inpatient hospital or skilled nursing facility (SNF) stay can be confusing and difficult. Medicare Part B covers care coordination (also called transitional care management) if you need assistance organizing your care after leaving a facility, whether you were an inpatient or an outpatient. Your primary care provider (PCP) may automatically provide care coordination, or you can request services by asking that your hospital or SNF notify your PCP about your discharge home.

Under this benefit, you should receive an in-person visit from your provider within 7 or 14 days of your return home, depending on the complexity of your condition. Your provider should offer the following services, as necessary:

  • Contact you within two days of leaving the hospital or SNF
  • Work with your other health care providers to provide education and other services to help you transition back to living at home
  • Review your need for follow-up visits and help you schedule them
  • Identify medical needs you have and arrange referrals to follow-up care and other community resources


Part B covers care coordination after a hospital or SNF stay at 80% of the Medicare-approved amount if you receive the service from a participating provider. You pay a 20% coinsurance after you meet your Part B deductible ($198 in 2020).

If you have questions about receiving this benefit, speak to your primary care provider.

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