(Medicare General Information, Eligibility, and Entitlement)

20.3 - Part B Coinsurance  (Rev. 1, 09- 11-02)  After the deductible has been satisfied, coinsurance of 20 percent is usually applicable.   For providers and suppliers that bill A/B MAC(A) or (HHH), the 20 percent may be based on the allowed amount, billed charges, or a preset rate per service (APC), depending upon the type of service.  See Claims Processing instructions for a description of coinsurance calculation for each benefit type.   Physicians and other suppliers will be paid 80 percent of allowed amount under the fee schedule amounts or in some instances reasonable charges incurred during the balance of the calendar year.  The patient is responsible for a coinsurance amount equal to 20 percent of the fee schedule amounts or reasonable charges for the items and services. (See 20.4 of this chapter for exceptions.)   20.4 - Exceptions to Annual Deductible and Coinsurance  (Rev. 11, Issued: 10- 22-04, Effective: 11 -22-04, Implementation: 11- 22-04)  There is no deductible for screening mammography effective for services January 1, 1998 and later.   Neither the annual deductible nor the 20 percent coinsurance apply with respect to:    Parts A and B home health services, except that there is a coinsurance of 20 percent of the payment amount for supplies, drugs, DME and prosthetics /orthotics furnished as a home health benefit;   Clinical diagnostic laboratory tests (including specimen collection fees) performed or supervised by a physician, laboratory, or other entity paid on an assigned basis;   Pneumococcal vaccine and its administration;   Influenza vaccine and its administration; and   Services or items denied as medically unnecessary.   NOTE:  Services which are not subject to the deductible cannot be used to satisfy the deductible.   20.4.1 - Applications of Deductible and Coinsurance in Liability and Indemnification Situations  (Rev. 12, Issued:  10- 22-04, Effective:  04 -01-05, Implementation:  04- 04-05)  Under 1879 of the Act, a beneficiary is not responsible for payment of the Part B deductible or coinsurance for items or services that are neither reasonable and necessary to diagnose or treat the illness or injury, nor to improve the functioning of a malf ormed body member.  If the provider knew, or should have known, that Medicare considered such services medically unnecessary, but failed to inform the beneficiary before furnishing them, the provider is held liable for their cost.  If the beneficiary made payment for such items or services, he/she can be indemnified for them.   In most cases, however, funds can be collected while awaiting the outcome of review of a demand bill for institutional services -- See Publication 100- 04, Chapter 1, 60.3, See 60.3.1 in the same chapter for specific information on limitations on collecting funds from beneficiaries in SNF Part A stays.  In general, see Chapter 30 of that publication for information on limitation of liability.   20.5 - Blood Deductibles (Part A and Part B)  (Rev. 1, 09- 11-02)  Program payment may not be made for the first 3 pints of whole blood or equivalent units of packed red cells received under Part A and Part B combined in a calendar year.  However, blood processing (e.g., administration, storage) is not subject to the deductible.   The blood deductibles are in addition to any other applicable deductible and coinsurance amounts for which the patient is responsible.  The deductible applies only to the first 3 pints of blood furnished in a calendar year, even if more than one provider furnished blood.   20.5.1 - Part A Blood Deductible  (Rev. 1, 09- 11-02)  Blood must be furnished on a Medicare covered day in a hospital or SNF to be counted under Part A.  Blood furnished to an inpatient after benefits exhausted or before entitlement is not counted toward the combined deductible.  Blood furnished during a lifetime extension election period is counted toward the combined A/B 3 pint total.  20.5.2 - Part B Blood Deductible  (Rev. 1, 09- 11-02)  Blood is furnished on an outpatient basis or is subject to the Part B blood deductible and is counted toward the combined limit.  It should be noted that payment for blood may be made to the hospital under Part B only for blood furnished in an outpatient s etting.  Blood is not covered for inpatient Part B services.   20.5.3 - Items Subject to Blood Deductibles  (Rev. 18, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  The blood deductibles apply 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 consi dered equivalent to a pint of whole blood.  Other components of blood such as platelets, fibrinogen, plasma, gamma globulin, and serum albumin are not subject to the blood deductible.  However, these components of blood are covered as biologicals.  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, 231 regarding billing for blood and blood products under the Hospital Outpatient Prospective Payment System (OPPS).   20.5.4 - Obligations of the Beneficiary to Pay for or Replace Deductible Blood  (Rev. 1, 09- 11-02)  A provider may charge the beneficiary or a third party its customary charge for whole blood or units of packed red cells which are subject to either the Part A or Part B blood deductible, unless the individual, another person, or a blood bank replaces the blood or arranges to have it replaced.   20.5.4.1 - Replacement of Blood  (Rev. 1, 09- 11-02)  For replacement purposes, a pint of whole blood is considered equivalent to a unit of packed red cells.  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.  Accordingly, where an individual or a blood bank offers blood as a replacement for a deductible pint or unit furnished a Medicare beneficiary, the provider may not charge the beneficiary for the blood, whether or not the provider or its blood supplier accepts the replacement offer.  Thus a provider may not charge a beneficiary merely because it is the policy of t he provider or its blood supplier not to accept blood from a particular source which has offered to replace blood on behalf of the beneficiary.  However, a provider would not be barred from charging a beneficiary for deductible blood, if there is a reasona ble basis for believing that replacement blood offered by or on behalf of the beneficiary would endanger the health of a recipient or that the prospective donor's health would be endangered by making a blood donation.  Once a provider accepts a pint of replacement blood from a beneficiary or another individual acting on his/her behalf, the blood is deemed to have been replaced, and, the beneficiary may not be charged for the blood, even though the replacement blood is later found to be unfit and has to be discarded.   When a provider accepts blood donated in advance, in anticipation of need by a specific beneficiary, whether the beneficiary's own blood, that is, an autologous donation, or blood furnished by another individual or blood assurance group, such donations are  considered replacement for pints or units subsequently furnished the beneficiary.    20.6  Part B Premium  (Rev. 12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  The Centers for Medicare and Medicaid Services (CMS) updates the Part B premium each year. These adjustments are made according to formulas set by statute. By law, the monthly Part B premium must be sufficient to cover 25 percent of the programs costs, including the costs of maintaining a reserve against unexpected spending increases.  The federal government pays the remaining 75 percent.   Below are the annual Part B premium amounts from Calendar Year (CY) 1996 to 2006. For these years, and years prior to 1996, the Part B premium is a single established rate for all beneficiaries.   Year  Part B Premium  1996  $42.50  1997  $43.80  1998  $43.80  1999  $45.50  2000  $45.50  2001  $50.00  2002  $54.00  2003  $58.70  2004  $66.60  2005  $78.20  2006  $88.50   Beginning on January 1, 2007, the Part B premium is based on the income of the beneficiary. See the following Change Requests (CRs) for more information.  For 2008, see CR 5345 at http://www.cms.hhs.gov/transmittals/downloads/R41GI.pdf   For 2008, see CR 5830 at http://www.cms.hhs.gov/transmittals/downloads/R49GI.pdf   For 2009, see CR 6258 at http://www.cms.hhs.gov/transmittals/downloads/R56GI.pdf   For 2010, see CR 6690 found on the 2009 Transmittals page at http://www.cms.hhs.gov/Transmittals/2009Trans/list.asp For 2011, see CR 7224 found on the 2010 Transmittals page at http://www.cms.gov/Transmittals/2010Trans/list.asp For 2012, see CR 7567 found on the 2011 Transmittals page at http://www.cms.gov/Transmittals/2011Trans/list.asp For 2013, see CR 8052 found on the 2012 Transmittals page at http://www.cms.gov/Transmittals/2012Trans/list.asp For 2014, see CR 8527 found on the 2013 Transmittals page at http://www.cms.gov/Transmittals/2013Trans/list.asp For 2015, see CR 8982 found on the 2014 Transmittals page at http://www.cms.gov/Transmittals/2014Trans/list.asp For 2016, see CR 9410 found on the 2015 Transmittals page at http://www.cms.gov/Transmittals/2015Trans/list.asp For 2017, see CR 9902 found on the 2016 Transmittals page at http://www.cms.gov/Transmittals/2016Trans/list.asp For 2018, see CR 10405 found on the 2017 Transmittals page at http://www.cms.gov/Transmittals/2017Trans/list.asp For 2019, see CR 11025 found on the 2018 Transmittals page at http://www.cms.gov/Transmittals/2018Trans/list.asp For 2020, see CR 11542 found on the 2019 Transmittals page at  http://www.cms.gov/Transmittals/2019Trans/list.asp For 2021, see CR 12024 found on the 2020 Transmittals page at  http://www.cms.gov/Transmittals/2020Trans/list.asp For 2022, see CR 12507 found on the 2021 Transmittals page at  http://www.cms.gov/Transmittals/2021Trans/list.asp For 2023, see CR 12903 found on the 2022 Transmittals page at  http://www.cms.gov/Transmittals/2022Trans/list.asp For 2024, see CR 13365 found on the 2023 Transmittals page at  http://www.cms.gov/Transmittals/2023Trans/list.asp   30 - Outpatient Mental Health Treatment Limitation  (Rev. 60, Issued: 10- 30-09, Effective: 01 -01-10, Implementation: 01- 04-10)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  The limitation is called the outpatient mental health treatment limitation (the limitation).  The 62 .5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).