Between Virginia's $2.00 per Medicaid enrollee in transitional care management spending and Florida's $0.02, there is a 100-fold gap. That gap is a proxy for something more consequential than billing patterns: it reflects how reliably states ensure that high-risk patients have a physician contact within two weeks of leaving the hospital.

Transitional care management codes (99495 and 99496) exist precisely to reduce that window of vulnerability. When a state barely bills them, it's not because its patients don't need follow-up. It's because the follow-up isn't happening, or isn't being documented, or both.

Virginia and Michigan Show What Engagement Looks Like

Virginia spent $3,790,995 on TCM across 36,409 claims, yielding $2.00 per enrollee across a Medicaid population of roughly 1.9 million. Michigan filed the most TCM claims of any state at 41,241, with $3,266,296 in total spending and $1.16 per enrollee. The District of Columbia, with a much smaller population, reached $1.58 per enrollee.

These numbers suggest active, organized post-discharge workflows. At $2.00 per enrollee, Virginia is billing TCM at a rate that implies a meaningful share of eligible discharges are actually being captured. For Medicaid patients, who face higher rates of chronic illness, housing instability, and limited transportation, that follow-up contact can be the difference between a stable recovery and a return trip to the emergency department.

California complicates the picture. It had the highest absolute TCM spending at $4,221,465 across 37,197 claims, but its 14.6 million Medicaid enrollees dilute that to just $0.29 per enrollee. Scale matters here: California's raw volume looks impressive until you account for the denominator.

Florida and Illinois Are Effectively Opting Out

Florida's numbers are difficult to explain away. With 5,211,017 Medicaid enrollees, the state spent $94,277 on TCM across 6,362 claims, producing $0.02 per enrollee. Illinois, with a similarly large Medicaid population of over 3.4 million, spent $67,144 across just 1,064 claims, also at $0.02 per enrollee.

At $0.02 per enrollee, these states are not running low-volume TCM programs. They are running programs that are functionally absent. For every dollar Virginia spends per enrollee on post-discharge coordination, Florida spends two cents. The patients being discharged from Florida hospitals into Medicaid coverage are not receiving meaningfully different care than Virginia's patients in terms of clinical complexity. What differs is the infrastructure built around their discharge.

The consequences fall on patients first, then on the system. Uncoordinated discharges produce readmissions, and readmissions are expensive. A state that doesn't bill TCM is, in effect, paying for the downstream costs of skipping the cheaper intervention.

A Growing National Program Still Dominated by Organizations

Nationally, TCM billing has grown. Total paid rose from $1,580,000 in 2018 to $2,973,268 in 2024, nearly doubling over six years. Claims peaked at 38,555 in 2023 before declining to 31,783 in 2024, while average monthly beneficiaries grew from 21.43 to 24.44 over the same period.

The provider composition is striking. Organizations account for 98.01% of total TCM paid ($14,309,240) and 95.71% of total claims. Individual providers represent just 1.91% of total paid. This is not a program driven by solo practitioners calling patients after discharge. It is almost entirely an institutional billing function, concentrated in health systems and large group practices with the administrative capacity to track discharges, document outreach, and submit claims correctly.

That concentration has a practical implication. States with fragmented Medicaid delivery systems, or with large shares of fee-for-service enrollment outside of organized health systems, will structurally underperform on TCM billing regardless of clinical intent. The code requires a level of care coordination infrastructure that not every market has built.

What happens to Florida's 5.2 million Medicaid enrollees in the two weeks after discharge is a question the billing data raises but cannot answer. The readmission data, if matched to these states, probably can.