Autumn 2026·7 min read·Abloom Senior Living

Coming home after a transitional care unit stay

The coverage ends on a date somebody else picks. Here is how to be ready for it.

Why this comes up

Your parent is in a transitional care unit, therapy is going reasonably well, and somebody in a hallway conversation has mentioned a discharge date. You are trying to work out what happens on that date and who will be at the house. The information reaches you in pieces, from different people, on a schedule nobody explains, which is why families often feel a step behind.

Most families start on this a few days before a discharge date. Almost nobody learns these rules before needing them, and you are likely meeting this part of the system for the only time, under a deadline, while holding down a job.

What the transitional care unit stay is paying for

In Minnesota, a short skilled nursing stay after a hospital admission is usually called a transitional care unit, or TCU. Medicare calls the same care skilled nursing facility care, and the coverage rules travel under Medicare's name for it, which is part of why the paperwork and the hallway conversations do not match.

Medicare's page on skilled nursing facility care gives the rules and the amounts. Part A pays after a medically necessary inpatient hospital stay of at least three days in a row, not counting the day of discharge, and time under observation does not count toward those three days. Coverage is capped at 100 days in each benefit period. For 2026, Medicare lists days 1 through 20 at $0 a day once the $1,736 deductible is paid, days 21 through 100 at $217 a day, and day 101 onward as your family's full cost.

The 100 days is an outer limit. A stay can end far earlier, whenever the skilled need the coverage rests on is documented as met, and most stays do end earlier. If your parent is on a Medicare Advantage plan, that plan sets its own version of these rules, so ask member services whether the plan requires the three-day hospital stay and how it counts covered days.

How the coverage ends, and how much notice you get

Coverage usually ends with a written notice. Medicare's page on fast appeals says the facility has to give a Notice of Medicare Non-Coverage at least two days before covered services end. If you want that decision reviewed, the same page says you follow the instructions on the notice "no later than noon the day before the termination date listed on the notice." An independent reviewer, called a BFCC-QIO, then decides by close of business the day after it has the information it needs.

Two days is very little time to arrange a house, and families tell us they felt ambushed by it. Medicare's page also covers what a review that goes against you means for the bill: you are not responsible for covered services provided before the end date on the notice, and you may have to pay for services after it.

The review itself is a phone call. You do not need a lawyer or a form of your own, and asking for it does not pause your planning or commit you to anything. If a notice is already in your hand and the date is tomorrow, the instructions printed on it are the whole process, and you can start there while you keep working on home.

What Medicare pays for once your parent is home

Home health is a separate benefit with separate rules. Medicare's page on home health services says the care must be ordered by a doctor or other provider, your parent has to be homebound, and the skilled need has to be part-time or intermittent. That buys nurse visits, physical, occupational, or speech therapy, medical social services, and some home health aide time attached to the skilled plan of care.

The same page lists what the benefit leaves out. Medicare does not pay for "24-hour-a-day care at your home." It does not pay for homemaker services such as shopping and cleaning that are unrelated to the care plan. It does not pay for custodial or personal care that helps with bathing, dressing, or using the bathroom "when this is the only care you need."

The exclusion for personal care is the one families run into, because the help a parent needs in week one is mostly bathing, dressing, and getting to the bathroom. The two kinds of care sit side by side on our home care or home health page, and what Medicare does and does not cover goes through it in more detail.

Who covers which hours

Counting the Medicare days is the right first question and almost everyone asks it first. It answers less than families expect, because the days Medicare covers and the hours your parent needs someone in the room are two different lists.

Before the discharge meeting, write out the day as it will run. Mornings mean getting out of bed, the bathroom, dressing, breakfast, and the first medications. The therapist comes mid-morning, twice a week, for under an hour. Afternoons are usually quiet. Evenings mean dinner, the bathroom again, and getting back into bed around seven or eight, which is the hour when somebody with new balance trouble tries all of it alone. Overnight depends on what wakes them.

Then put a name next to each block. The blocks with nobody's name on them are the ones you are buying, asking family to cover, or going without. Filling it in is uncomfortable, and easier than working the same thing out on the first night at home.

Personal care at home is paid for privately or through a long-term care insurance policy. Abloom Senior Living takes private pay and long-term care insurance for care in a client's own home, and does not bill Minnesota waivers or Medical Assistance for in-home services, so a family whose plan depends on waiver funding gets that answer straight from us along with a referral. Overnight hours are staffed as awake shifts, so no caregiver sleeps at the house. If the overnight block is the one with no name on it, ask about that one first, because it usually decides whether the rest of the plan works.

What changed while your parent was away

The house your parent comes back to is usually different from the one they left. The medication list will not match the one on the refrigerator door. The walker may be new and set to a different height. There may be a hospital bed arriving, an oxygen concentrator with tubing crossing a hallway, or a bathroom that no longer works for somebody using a walker.

Some care starts during the TCU stay: a feeding tube, oxygen, BiPAP at night, or transfers that now take two people. If any of those apply, ask each agency whether they do that work in homes, how often, and which nurse is responsible for it. Nursing care at home describes what those visits involve, and who can give your parent their medications at home explains who is allowed to do what in Minnesota.

What an agency has to do in the first two weeks

Minnesota writes some of this into statute, with deadlines you can hold a provider to.

Within five days of the first shift, a registered nurse has to come to the house in person and assess your parent. Within 14 days you should have a written service plan naming the services and fees, how often each one happens, who is providing it, and a contingency plan for interruptions and emergencies. Both deadlines sit in Minn. Stat. 144A.4791, subdivisions 8 and 9, for providers delivering comprehensive home care services, so it is fair to ask for them by name.

Subdivision 3 requires a written statement of services naming which license the provider holds, what it is authorized to provide, and which services it "cannot provide under the scope of the provider's license." Ask for it before the first shift, and read the list of services the provider cannot supply. Questions to ask a home care provider is a list you can take into the call.

If home care does not work out

Some homecomings do not work, and the reason is usually cost rather than anything anyone did wrong. The hours the day turns out to need come to more than the family can carry month after month, or the overnight need is constant, or the one person holding it together has a job that will not bend further.

Abloom Senior Living also operates a five-resident customized living home in Woodbury, one of several options in the East Metro if the hours stop adding up, and families who start with care at home sometimes move there later. When to consider a move goes through the signs that show up first.

What can wait

The hours for the first week need a decision before discharge, and a good deal of the rest can wait.

You do not have to decide in a TCU hallway whether this is permanent, and in most cases nobody knows yet, including the therapists. Whether the house needs a bathroom remodel can wait until you have watched somebody use it for two weeks. Whether your parent should eventually move can wait until the immediate weeks are settled. A long-term care insurance claim can be opened after your parent is home, though policies set their own timing and many have an elimination period, so read that section before you assume either way.

In two weeks you will have watched the actual days, so it is reasonable to leave some of this until then.

This article is general information from a care provider in Woodbury, Minnesota, and it is not legal, financial, or medical advice. Coverage rules, dollar figures, and program details change, and your family's situation contains facts no article can see. Check anything that matters for your decision with the plan, the program, or your own advisor.

Where to start

If a discharge date is coming and the hours are still open, the useful next step is to have somebody look at the real day with you and say what it would take to cover it. You can request in-home care through the form, and we will come to the house, or you are welcome to come see the Woodbury home and ask your questions there.

You are probably calling several agencies. If what your family needs is not what Abloom Senior Living does, we will tell you that and point you toward someone who does it. Minnesota Aging Pathways, a free statewide service of the Minnesota Board on Aging and the state's area agencies on aging, answers questions at 800-333-2433 on weekdays from 8:00 a.m. to 4:30 p.m.

Frequently asked questions

How many days will Medicare pay for a transitional care unit stay?

Medicare limits skilled nursing facility coverage to 100 days in each benefit period, and Medicare's coverage page lists days 1 through 20 at $0 a day once the 2026 deductible of $1,736 is paid, days 21 through 100 at $217 a day, and day 101 onward at your own cost. Most stays end well before day 100, because the coverage depends on a continuing skilled need. Medicare Advantage plans apply their own rules and should be asked directly.

What notice do we get before the coverage ends?

Medicare's fast appeals page says the facility must give a Notice of Medicare Non-Coverage at least two days before covered services end. If you want the decision reviewed, you follow the instructions on that notice by noon the day before the termination date it lists, and an independent reviewer decides by close of business the day after it has what it needs.

Will Medicare home health send somebody to help my mother get up and dressed every morning?

No, and many families expect otherwise. Medicare's home health page covers part-time or intermittent skilled care for a homebound patient, and states that the benefit does not pay for 24-hour-a-day care at home, for homemaker services unrelated to the care plan, or for personal care such as bathing and dressing when that is the only care needed. Daily help with the morning routine is paid for privately or through long-term care insurance.

Can care at home handle a feeding tube or oxygen that started in the TCU?

It depends on the agency, so ask about the specific task by name and ask how often they do it. Abloom Senior Living does this work in homes: tracheostomy care without a ventilator, G, J, and GJ tube feeding, BiPAP, CPAP, and oxygen, two-person transfers, and dementia care at home. Other agencies do some of it as well, and any Minnesota provider has to give you a written statement of services naming what it cannot do under its license, which is the quickest way to check.

How soon after discharge does a home care agency have to write a plan?

Under Minn. Stat. 144A.4791, a provider delivering comprehensive home care services must have a registered nurse complete an in-person initial assessment within five days, and must finish the service plan within 14 days, including the fees, the frequency of services, who provides them, and a contingency plan for interruptions and emergencies.

Sources

All field notes Arrange a visit