Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019

To amend title XVIII of the Social Security Act to ensure equitable payment for, and preserve Medicare beneficiary access to, diagnostic radiopharmaceuticals under the Medicare hospital outpatient prospective payment system. 1. Short title This Act may be cited as the Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 2. Separate payment for certain diagnostic radiopharmaceuticals (a) In general Section 1833(t)(16) of the Social Security Act ( 42 U.S.C. 1395l(t)(16) (G) Separate payment for certain diagnostic radiopharmaceuticals (i) In general Notwithstanding any other provision of this subsection, with respect to services furnished on or after January 1, 2020, the Secretary shall not package, and shall make a separate payment as specified in clause (ii) for, a diagnostic radiopharmaceutical defined in clause (v) with an estimated mean per day product cost equal to or exceeding the threshold specified in clause (iii). (ii) Separate payment For purposes of clause (i), payment specified in this clause for a diagnostic radiopharmaceutical described in clause (i) shall be equal to— (I) the average sales price for the drug established under section 1847A, to the extent the average sales price is available, as calculated and adjusted by the Secretary to the extent such adjustment is adopted for other specified covered outpatient drugs under paragraph (14)(A); or (II) if the data necessary to calculate the average sales price for the drug in the year under the sections specified in subclause (I) is not available, the wholesale acquisition cost as defined in subsection 1847A(c)(6)(B), or, if the wholesale acquisition cost is not available, the mean unit cost data derived from hospital claims data. (III) Nothing in this subparagraph shall be construed as affecting eligibility of diagnostic radiopharmaceuticals for pass-through payments under paragraph (6). (iii) Threshold For purposes of this subparagraph, the threshold specified in this clause— (I) for 2020, is $500; and (II) for subsequent years, is the amount specified in this clause for the preceding year increased by the percentage of the OPD fee schedule increase factor under paragraph (3)(C)(iv) for the applicable year. (iv) Budget neutrality The Secretary shall make such adjustments as are necessary under subparagraph 9(B) to ensure that the amount of expenditures under this subsection for such year with application of this subparagraph is equal to the amount of expenditures that would be made under this subsection for such year without application of this subparagraph. (v) Definition For purposes of this subparagraph, a diagnostic radiopharmaceutical is a drug or biological that is described in section 315.2(a) of title 21, Code of Federal Regulations, or any successor regulation, and is approved by the Food and Drug Administration on or after January 1, 2008. . (b) No impact on copayment Section 1833(t) of the Social Security Act ( 42 U.S.C. 1395l(t)(8)(E) (1) inserting AND SEPARATE PAYMENTS FOR CERTAIN DIAGNOSTIC RADIOPHARMACEUTICALS PASS–THROUGH ADJUSTMENTS (2) inserting after such adjustments) and subparagraph (16)(G)

Summary: Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 This bill establishes separate payment requirements for diagnostic radiopharmaceuticals under the Medicare prospective payment system for hospital outpatient department services. The bill's requirements apply to diagnostic radiopharmaceuticals that have an average daily cost of $500 or more in 2020 and as adjusted based on a specified fee schedule factor in each year thereafter.