HI 00610.470 Medical Insurance Blood Deductible

A. General

Payment under Part B may not be made for the first three covered pints of whole blood, or equivalent units of packed red cells, received by a beneficiary in a calendar year. After the three pint (or unit) deductible has been satisfied, payment may be made for all blood charges, subject to the normal coverage and reasonable charge criteria.

There is also a Part A blood deductible applicable to the first three pints of whole blood or equivalent units of packed red cells received by a beneficiary in a benefit period. The Part A and Part B deductibles are applied separately. See HI 00601.580 for instructions on the Part A blood deductible.

B. Application of the blood deductible

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

The blood deductible involves only the charges for the blood or packed red cells. Charges for the administration of blood or packed cells are not subject to the blood deductible. Accordingly, although payment may not be made for the first three pints of blood and/or units of packed red cells furnished to a beneficiary in a calendar year, payment may be made (subject to the cash deductible) for the administration charges for all covered pints or units including the first three furnished in a calendar year.

The blood deductible applies only to the first three pints and/or units furnished in a calendar year, even though more than one physician or clinic furnished blood. Furthermore, to count toward the deductible, the blood must be covered with respect to all applicable criteria (i.e., it must be medically necessary, it must be furnished incident to a physician's services, etc.).

C. Distinction between blood charges and blood administration charges

Since the blood deductible applies only to charges for the blood and does not apply to charges for blood administration, these two charges must be considered separately. Where the bill for services rendered (or the HCFA-1490) shows only a single charge for blood, the portion of the single charge that is considered to be a charge for blood administration is determined by reference to the established customary and prevailing reasonable charge methodology in the locality as it applies to blood administration.

D. Relationship to other deductibles

Part B reimbursement for all blood administration charges and for blood charges after the beneficiary has received three pints and/or units in a calendar year is subject to the annual cash deductible and coinsurance provisions. Expenses incurred in meeting the Part B blood deductible do not count as incurred expenses under Part B for purposes of meeting the Part B annual cash deductible or for purposes of reimbursement.

E. Example of application of the Part B blood deductible

During 1982, a beneficiary received three pints of blood from a physician for which the charge was $50 per pint. The physician does not impose a separate charge for blood administration. The beneficiary obtains an itemized bill for the services and submits a claim for Part B reimbursement.

The beneficiary has not met any part of the Part B blood deductible and has met only $40 of the cash deductible. The carrier determines that the physician's customary charge for blood administration is $15 and that is reasonable. Consequently charges for blood administration are $15 per pint or a total of $45 for the three pints furnished and charges for blood are $35 per pint or a total of $105 for the three pints furnished.

Since the beneficiary has not met any of the Part B blood deductible, none of the $105 in blood charges are reimbursable nor may any of such charges be applied to satisfy the cash deductible. Of the $45 in blood administration charges, $35 is applied to satisfy the beneficiary's unmet cash deductible and a payment of $8 is made on the remaining $10 in charges. ($10 ×80%).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600610470