HI 00601.580 Part A Blood Deductible

There is also a Part B blood deductible which applies on a calendar year basis (see HI 00610.470). The Part A and Part B blood deductibles are applied separately.

A. Definition

The blood deductible applies only to whole blood and packed red cells. The term whole blood means human blood from which none of the liquid or cellular components have been removed. Where packed red cells are furnished, a unit of packed red cells is considered equivalent to a pint of whole blood. Other components of blood such as platelets, fibrinogen, plasma, gamma globlin, and serum albumin are not subject to the blood deductible. However, these components of blood are covered as biologicals.

B. Blood deductible

Program payment may not be made for the first three pints of whole blood or equivalent units of packed red cells received by a beneficiary in a benefit period. However, payment may be made for blood processing beginning with the first pint or unit in a benefit period. The blood deductible is in addition to any other applicable deductible and coinsurance amounts for which the patient is responsible.

To be covered a Part A service and count toward the blood deductible, the blood must be furnished on a day which counts as a day of inpatient hospital services or extended care services. Thus, blood is not covered under Part A and does not count toward the Part A blood deductible when furnished to an inpatient after he has exhausted his benefit days in a benefit period, or where the individual has elected not to use lifetime reserve days. However, where the patient is discharged on his first day of entitlement, the provider is permitted to submit a billing form with no accommodation charge, but with ancillary charges including blood.

When the beneficiary is subject to the blood deductible, he has the option of replacing the blood on a pint-for-pint or unit basis, or paying the provider's charges for the unreplaced pints.

When a beneficiary elects to replace deductible pints or units, it is considered replaced if the patient or someone else, e.g., a volunteer blood bank organization, replaces the blood on his behalf. For Medicare purposes, replacement is made on a pint-for-pint or unit basis. Although a provider is free to persuade a beneficiary to arrange for donation of more blood than was required to meet the deductible provisions, no charge may be made to a beneficiary who does not comply with the request if he has replaced, or arranged to be replaced, on a pint-for-pint or unit basis, each of the blood deductible pints he received.

Where more blood is donated on behalf of the beneficiary than is needed for full replacement on a pint-for-pint or unit basis, the value of the excess blood is not deducted from the amount payable to the provider. However, such donations would tend to reduce the cost of blood to the provider. Where a provider accepts blood donated in advance for or by a beneficiary in anticipation of need, such donations are considered as replacement for any deductible pints or units subsequently furnished him in the future.

C. Obligation of the beneficiary to pay for or arrange to replace deductible blood

A beneficiary who receives blood (or packed red cells) which is subject to the blood deductible, has the option of arranging to replace the blood or paying the provider's charges for the unreplaced pints.

1. Prohibition on charging for replaced deductible blood

A beneficiary may not be charged for deductible blood which he has replaced, or arranged to replace. A deductible pint of whole blood or unit of packed red cells is considered replaced when a medically acceptable pint or unit is given or offered to the provider, or at the provider's request, to its blood supplier, whether or not the provider accepts the offer. A provider may not charge a beneficiary because its policy is not to accept blood from a particular organization which has offered to replace blood on the beneficiary's behalf. However, a provider is not barred from charging a beneficiary for deductible blood, if replacement blood offered by or on behalf of the beneficiary would endanger the health of either the donor or a recipient.

2. Charges for deductible blood

If the beneficiary does not replace, or make arrangements to replace, deductible blood (or packed red cells), he may be charged the provider's usual and customary charges for the blood. Charges for processing blood or packed red cells, e.g., for administration, or storage are covered without regard to the deductible and billed to the program beginning with the first pint or unit.

3. Replacement

For Medicare purposes, replacement is made on a pint-for-pint basis. Thus, a beneficiary cannot be charged for deductible blood if he replaced or arranged to replace each pint or unit furnished him.

Once a provider accepts a pint of replacement blood from a beneficiary or another source acting on his behalf, replacement has been made, i.e., the beneficiary may not be charged for blood, even though the blood is later found to be unfit and is discarded.

When a provider accepts blood donated in advance, in anticipation of need by a specific beneficiary, the donations are considered replacements for the pints or units subseq