[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR410.63]



[Page 348]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents

 

               Subpart B_Medical and Other Health Services

 

Sec. 410.63  Hepatitis B vaccine and blood clotting factors: Conditions.



    Notwithstanding the exclusion from coverage of vaccines (see Sec. 

405.310 of this chapter) and self-administered drugs (see Sec. 410.29), 

the following services are included as medical and other health services 

covered under Sec. 410.10, subject to the specified conditions:

    (a) Hepatitis B vaccine: Conditions. Effective September 1, 1984, 

hepatitis B vaccinations that are reasonable and necessary for the 

prevention of illness for those individuals who are at high or 

intermediate risk of contracting hepatitis B as listed below:

    (1) High risk groups. (i) End-Stage Renal Disease (ESRD) patients;

    (ii) Hemophiliacs who receive Factor VIII or IX concentrates;

    (iii) Clients of institutions for the mentally retarded;

    (iv) Persons who live in the same household as a hepatitis B 

carrier;

    (v) Homosexual men;

    (vi) Illicit injectable drug abusers; and

    (vii) Pacific Islanders (that is, those Medicare beneficiaries who 

reside on Pacific islands under U.S. jurisdiction, other than residents 

of Hawaii).

    (2) Intermediate risk groups. (i) Staff in institutions for the 

mentally retarded and classroom employees who work with mentally 

retarded persons;

    (ii) Workers in health care professions who have frequent contact 

with blood or blood-derived body fluids during routine work (including 

workers who work outside of a hospital and have frequent contact with 

blood or other infectious secretions); and

    (iii) Heterosexually active persons with multiple sexual partners 

(that is, those Medicare beneficiaries who have had at least two 

documented episodes of sexually transmitted diseases within the 

preceding 5 years).

    (3) Exception. Individuals described in paragraphs (a) (1) and (2) 

of this section are not considered at high or intermediate risk of 

contracting hepatitis B if they have undergone a prevaccination 

screening and have been found to be currently positive for antibodies to 

hepatitis B.

    (b) Blood clotting factors: Conditions. Effective July 18, 1984, 

blood clotting factors to control bleeding for hemophilia patients 

competent to use these factors without medical or other supervision, and 

items related to the administration of those factors. The amount of 

clotting factors covered under this provision is determined by the 

carrier based on the historical utilization pattern or profile developed 

by the carrier for each patient, and based on consideration of the need 

for a reasonable reserve supply to be kept in the home in the event of 

emergency or unforeseen circumstance.

    (c) Blood clotting factors: Furnishing Fee. (1) Effective January 1, 

2005, a furnishing fee of $0.14 per unit of clotting factor is paid to 

entities that furnish blood clotting factors unless the costs associated 

with furnishing the clotting factor are paid through another payment 

system, for example, hospitals that furnish clotting factor to patients 

during a Part A covered inpatient hospital stay.

    (2) The furnishing fee for blood clotting factors furnished in 2006 

or a subsequent year is be equal to the furnishing fee paid the previous 

year increased by the percentage increase in the consumer price index 

for medical care for the 12-month period ending with June of the 

previous year.



[55 FR 22790, June 4, 1990; 55 FR 31186, Aug. 1, 1990, as amended at 69 

FR 66422, Nov. 15, 2004]