Sponsors (6)
The bill improves transparency and reimbursement for high-cost outpatient cancer drugs—helping access and stabilizing provider payment—while risking higher patient cost-sharing, payment uncertainty, and offsets that could reduce other outpatient reimbursements due to its budget-neutral design.
Medicare beneficiaries will have high-cost outpatient cancer drugs billed and paid separately, increasing price transparency and making it easier to identify and secure access to these therapies.
Taxpayers and the Medicare program are protected from an overall increase in outpatient department (OPD) spending because the carve-out must be budget-neutral, limiting added cost pressure on the program.
Hospitals and health systems treating patients with expensive outpatient cancer drugs can receive more accurate reimbursement for those drugs, reducing financial losses when providing high-cost therapies.
Medicare beneficiaries could face higher out-of-pocket cost-sharing because coinsurance tied to separately billed drug prices may increase patient payments for high-cost cancer drugs.
Budget-neutrality offsets could reduce payments elsewhere in the OPD fee schedule, lowering reimbursements for other outpatient services and ancillary care and potentially shifting costs or reducing access.
If ASP or WAC data are unavailable and CMS uses claims-based mean unit costs, payments may lag or be imprecise, creating short-term cash-flow and pricing uncertainty for providers and patients.
Based on analysis of 2 sections of legislative text.
Requires Medicare to pay separately for certain high-cost cancer drugs/biologics in hospital outpatient departments starting in 2026, with budget-neutral offsets and specified pricing fallbacks.
Introduced March 20, 2026 by Neal Patrick Dunn · Last progress March 20, 2026
Requires Medicare to pay separately for certain high-cost cancer drugs and biologics given in hospital outpatient departments beginning in 2026, instead of including their cost inside the bundled outpatient department (OPD) payment. Drugs meeting an annual estimated mean per day product cost threshold ($350 in 2026, then increased by the OPD fee schedule increase factor) will be paid outside the OPD bundle using average sales price (ASP) or fallback prices, while the Secretary must apply budget-neutral adjustments so total Medicare spending under the affected OPD payment subsection does not increase. Applies only to drugs and biologics approved by the FDA on or after January 1, 2008 that do not already have transitional pass-through payment status and that otherwise would be packaged into OPD payments; implements payment-method fallbacks (ASP, then WAC, then mean unit cost from hospital claims) and requires CMS to identify treatments that meet the cost threshold each year.