§ 412.88 Additional payment for new medical service or technology. Cross Reference
Link to an amendment published at 89 FR 69910 , Aug. 28, 2024.
( a ) For discharges involving new medical services or technologies that meet the criteria specified in § 412.87, Medicare payment will be: ( 1 ) One of the following: ( i ) The full DRG payment (including adjustments for indirect medical education and disproportionate share but excluding outlier payments);
( ii ) The payment determined under § 412.4(f) for transfer cases;
( iii ) The payment determined under § 412.92(d) for sole community hospitals; or
( iv ) The payment determined under § 412.108(c) for Medicare-dependent hospitals; plus
( 2 ) ( i ) *For discharges occurring before October 1, 2019.* If the costs of the discharge (determined by applying the operating cost-to-charge ratios as described in § 412.84(h)) exceed the full DRG payment, an additional amount equal to the lesser of— ( A ) 50 percent of the costs of the new medical service or technology; or
( B ) 50 percent of the amount by which the costs of the case exceed the standard DRG payment.
( ii ) *For discharges occurring on or after October 1, 2019.* ( A ) Except as provided under paragraph (a)(2)(ii)(B) of this section, if the costs of the discharge (determined by applying the operating cost-to-charge ratios as described in § 412.84(h)) exceed the full DRG payment, an additional amount equal to the lesser of— ( 1 ) 65 percent of the costs of the new medical service or technology; or
( 2 ) 65 percent of the amount by which the costs of the case exceed the standard DRG payment.
( B ) For a medical product designated by FDA as a Qualified Infectious Disease Product or, for discharges occurring on or after October 1, 2020, for a product approved under FDA's Limited Population Pathway for Antibacterial and Antifungal Drugs, if the costs of the discharge (determined by applying the operating cost-to-charge ratios as described in § 412.84(h)) exceed the full DRG payment, an additional amount equal to the lesser of— ( 1 ) 75 percent of the costs of the new medical service or technology; or
( 2 ) 75 percent of the amount by which the costs of the case exceed the standard DRG payment.
( b ) ( 1 ) *For discharges occurring before October 1, 2019.* Unless a discharge case qualifies for outlier payment under § 412.84, Medicare will not pay any additional amount beyond the DRG payment plus 50 percent of the estimated costs of the new medical service or technology.
( 2 ) *For discharges occurring on or after October 1, 2019.* Unless a discharge case qualifies for outlier payment under § 412.84, Medicare will not pay any additional amount beyond the DRG payment plus— ( i ) 65 percent of the estimated costs of the new medical service or technology;
( ii ) For a medical product designated by FDA as a Qualified Infectious Disease Product, 75 percent of the estimated costs of the new medical service or technology; or
( iii ) For discharges occurring on or after October 1, 2020, for a product approved under FDA's Limited Population Pathway for Antibacterial and Antifungal Drugs, 75 percent of the estimated costs of the new medical service or technology.
[66 FR 46924, Sept. 7, 2001, as amended at 67 FR 50111, Aug. 1, 2002; 69 FR 49244, Aug. 11, 2004; 72 FR 47411, Aug. 22, 2007; 84 FR 42612, Aug. 16, 2019; 85 FR 59021, Sept. 18, 2020]