Title: Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019
Policy area: Health

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.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3772 Introduced in House (IH)]

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116th CONGRESS
  1st Session
                                H. R. 3772

  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.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 16, 2019

  Mr. Peters (for himself, Mr. Rush, and Mr. Holding) introduced the 
   following bill; which was referred to the Committee on Energy and 
  Commerce, and in addition to the Committee on Ways and Means, for a 
 period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
  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.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Diagnostic 
Radiopharmaceutical Payment Equity Act of 2019''.

SEC. 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)) is amended by adding at the end the following new 
subparagraph:
                    ``(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)) is amended by--
            (1) inserting ``AND SEPARATE PAYMENTS FOR CERTAIN 
        DIAGNOSTIC RADIOPHARMACEUTICALS'' after ``PASS-THROUGH 
        ADJUSTMENTS''; and
            (2) inserting after ``such adjustments)'' the phrase ``and 
        subparagraph (16)(G)''.
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