Since 2025, a transfusion qualifies a transport for ALS2, a $237 step up from ALS1, while Howard County, Maryland paid $550 per unit of whole blood. A new TRICARE add-on and federal road safety grants help close the gap, and each one comes with limits an agency should budget around.
Educational reading for clinicians. Follow your current protocols and local guidance.
The Budget Question
NHTSA's Office of EMS put it plainly when it announced its October 28 EMS Focus session: after finding a blood supplier, funding is often the biggest challenge for an agency. The recording wasn't posted when I wrote this, so these numbers come from published programs and federal documents. For the evidence, see our SWiFT and TOWAR coverage; for rural logistics, our rural whole blood piece.
What a Program Costs
The most itemized public budget I found is Howard County, Maryland, published in JACEP Open in 2024. It put blood on three supervisor vehicles and expected 50 to 75 eligible patients a year.
| Item | Howard County cost |
|---|---|
| Initial equipment, each supervisor vehicle and station | ~$6,500 (2023) |
| Unit of whole blood | $550 |
| Administration equipment | ~$375 |
| Fluid warmer | $4,600 |
| Disposable warmer circuit | $87.50 |
| Estimated annual program cost | $46,250 to $69,375 ($925 per patient) |
The kit behind those numbers: Credo coolers with reusable thermal panels holding 1°C to 6°C for more than 24 hours, TracableLIVE temperature alerts over a cellular hotspot, filtered Y tubing, pressure infuser bags, a LifeFlow Plus and a QinFlow Warrior Lite warmer.
In a national survey in Transfusion, 33 of 53 agencies (62%) reported transfusion costs of $500 to $1,000 per patient. A Prehospital Blood Transfusion Coalition poll, reported by EMS1, averaged about $51,000 a year per program, from $36,276 for public non-fire EMS to $76,985 for aeromedical. In NHTSA's 2025 webinar Q&A, one panelist described a three-year trial estimated at $300,000, of which $270,000 was blood for a predicted 350 units. That works out to about $771 a unit, by my math.
Who Pays for the Unused Unit
Christina Warren, a blood bank manager at Atrium Health Wake Forest Baptist, laid out the two models on NHTSA's September webinar:
- Rotation: the blood center or hospital owns the blood and handles temperature validation. Unused units go back before they expire and cycle into inventory. She called this the best model for rural counties with low transfusion rates.
- Pay-as-you-go: EMS buys every unit and owns it. Without a rotation built in, unused units can be discarded. Hybrids exist, where a hospital takes a program's short-dated units.
In the Transfusion survey, 42 of 53 programs (79%) used one of these two arrangements. Dating sets the pace. Warren cited up to 21 days for whole blood, 28 for never-frozen liquid plasma and 42 for red cells, so component programs have more room.
Three published arrangements to bring to a supplier meeting:
- Howard County: the supplier took returns on day 14. The agency agreed to semiannual blood drives. Warren said drives help inventory and won't lower your price.
- Colorado Springs: a Level I trauma center supplies the blood. EMS uses a grant to pay for units it transfuses and returns unused units after 7 days.
- San Antonio Fire: 248 of 363 units (68.3%) were transfused in 12 months, with none lost to expiration. Field supervisors transfused 74% of their units against 44% for special operations ambulances, so placement matters too.
What Billing Returns
CMS added prehospital transfusion to the ALS2 list for 2025 for whole blood, red cells, plasma, or red cells with plasma. It added no separate payment, citing a lack of authority to create one. At the 2025 base rates in the Federal Register, ALS1 emergency pays $530.06 and ALS2 pays $767.20, a $237 difference. The Defense Health Agency's own analysis says whole blood alone costs more than that gap.
The real increment can be smaller. An intraosseous line also qualifies for ALS2, so by my reading, a patient who already has an IO may gain nothing from the transfusion on that claim. In the same PHBTC poll, average ground revenue rose only from $547 to $612 per patient treated with blood, and just 22% of agencies billed differently. In the Transfusion survey, 6 of 53 agencies (11%) reported any reimbursement at all.
The first separate payment starts January 1, 2027. The TRICARE demonstration runs through December 31, 2031, for medically necessary transfusion on ALS2, specialty care or air transports:
- Blood product: the higher of the hospital outpatient rate (listed at $189.84 per unit) or your invoiced cost. No invoice means you get the outpatient rate.
- Administration: CPT 36430, about $40, once per transport.
- Supplies: no separate payment. Warmers and IV supplies stay in the ALS2 bundle.
- Excluded: patients whose TRICARE isn't primary, among others.
America's Blood Centers calls itemized invoices the most important step, so ask your supplier for them now.
Where the Rest of the Money Comes From
| Route | Example | The catch |
|---|---|---|
| SS4A grants | FY25: 24 grants, $50 million. Tampa, $1,451,086, to train and certify 30 paramedics. | 20% non-federal match; roadway safety must be the primary purpose |
| Regional networks | Fargo-Moorhead, $960,000 SS4A, for a blood-sharing network within 30 minutes | Needs multi-agency agreement |
| CMS Rural Health Transformation | Colorado's $169.6 million award includes a rural EMS whole blood network reaching 39 counties | Depends on your state's plan |
| County funds | LA County Fire, $380,000 Productivity Investment Fund grant for equipment and blood | Launch money for a pilot in three battalions |
| Hospital partner | Hospital-owned programs, where costs go on the hospital bill | Needs a willing hospital |
| Existing budget | Howard County used reallocations and grants; training came from existing lines | Competes with other lines |
SS4A deserves a close read. The FY26 notice lists "Field Blood Delivery" as eligible under Implementation Grants. DOT reports 95 FY26 projects primarily focused on post-crash care and trauma support, totaling over $335 million, though that count isn't limited to blood.
Eligible applicants are MPOs, cities, counties, other political subdivisions and Tribal governments. States can't apply, and non-profits generally can't, so a private or non-profit service needs a government partner. Pre-award costs are ineligible, and funds must be spent within five years, so plan now for who pays for the blood after that. The FY26 application deadline was May 26.
A budget request should start with your invoiced price per unit, your supply model and your expected patients per year.
Sources
- NHTSA Office of EMS: Paying for Your Prehospital Blood Program
- American Ambulance Association: EMS Focus, Paying for Your Prehospital Blood Program (Oct. 6, 2026)
- JACEP Open: Levy et al., Implementation of a prehospital whole blood program, lessons learned (2024)
- Transfusion: Hurson et al., Evaluating reimbursement for prehospital blood transfusions, a nationwide survey (2025)
- Federal Register: TRICARE Demonstration Project for Ambulance Add-On Reimbursement for Pre-Hospital Blood Transfusion, 91 FR 40985 (July 6, 2026)
- CMS: Transmittal R13169BP, ALS2 list update
- AABB, America's Blood Centers, American Red Cross and Blood Centers of America: joint comments to CMS (Sept. 3, 2024)
- America's Blood Centers: How Blood Centers Can Support the TRICARE Demonstration Project
- NHTSA Office of EMS: Working with a Blood Supplier webinar transcript (Sept. 2026)
- NHTSA Office of EMS: EMS Week 2025 webinar FAQ
- Prehospital Emergency Care: Stewardship of prehospital low titer O-positive whole blood in a large urban fire-based EMS system (2022), abstract
- USDOT: FY26 SS4A Notice of Funding Opportunity
- USDOT: 2026 SS4A Awards
- EMS1: DOT announces $50M in grants for prehospital blood transfusion (Jan. 12, 2026)
- EMS1: Schaefer and Zavadsky, The economics of saving lives (Apr. 28, 2026)
- AABB: Federal funding to expand prehospital whole-blood transfusions in rural Colorado (Sept. 29, 2026)
- Los Angeles County Fire Department: $380K PIF grant awarded for LA-DROP pilot project (Dec. 20, 2024)
Jonathan B, career paramedic
Published November 2, 2026