3-13. MEDICARE/TFL COST SHARE TABLE Medicare — Part A
Medicare Pays
TFL Pays
You Pay
100% (after $1,556 deductible) All but $389 per day
Nothing for Medicare covered services.
$1,556 deductible
Days 1-60
Nothing for Medicare covered services. Nothing for Medicare covered services.
$389 per day
Days 61-90
Inpatient Hospital (Medical & Surgical Only)
All but $778 per day
$778 per day
Days 91-150*
Lesser of $250 per day or 25% of allowable charges if TFL network hospital; Lesser of $1,053 per day or 25% of allowable charges if non-network hospital.
Allowable charges less patient’s co-pay
Days 151 +
Not covered
Remaining liability (if any)
Nothing for Medicare covered services. Nothing for Medicare covered services.
Days 1-20
100%
All but $194.50 per day
$194.50 per day
Days 21-100
Skilled Nursing Facility
Lesser of $250 per day or 20% of allowable charges if TFL network hospital; 25% of allowable charges if non- network hospital.
Allowable charges less patient’s co-pay
Days 101 +
Not covered
Medicare — Part B
Doctors Visits (outside MTF)
Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services. Nothing for Medicare covered services.
80%
20%
80% of the facility and doctor’s charges
Emergency Room Visit
20%
Mental Health Visit
80%
20%
Laboratory Services
100%
Nothing
Radiology Services
80%
20%
Home Health Care
100%
Nothing
Durable Medical Equipment
80%
20%
Outpatient Hospital
80%
20%
CHAPTER 3: TRICARE
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