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Separates certain high‑cost cancer drugs from Medicare OPD bundled payments and requires separate reimbursement (ASP/WAC/claims‑based) starting in 2026 with a $350/day threshold and budget‑neutral offsets.
Official title: To amend title XVIII of the Social Security Act to ensure equitable payment for, and preserve Medicare beneficiary access to, cancer treatments under the Medicare hospital outpatient prospective payment system.
Introduced March 20, 2026 by Neal Patrick Dunn · Last progress March 20, 2026
The bill separates high-cost outpatient cancer drugs from bundled payments to improve transparency and provider reimbursement and protect access, but it risks higher patient cost-sharing, payment shifts within the outpatient fee schedule, and greater administrative and short-term payment uncertainty.
Medicare beneficiaries receiving high-cost outpatient cancer drugs will have those drugs billed and paid separately, improving price transparency and potentially preserving patient access to expensive therapies.
Hospitals and health systems can be reimbursed more accurately for expensive outpatient cancer drugs, reducing financial losses when treating patients who need high-cost therapies.
CMS will have a clear, data-driven payment hierarchy (ASP then WAC then claims-based mean unit cost) to set prices when public price data are incomplete, reducing payment disputes and administrative ambiguity.
Medicare beneficiaries may face higher out-of-pocket cost-sharing because coinsurance tied to the separately billed drug price could increase patients' expenses.
Budget-neutrality offsets may reduce payments elsewhere in the outpatient fee schedule, potentially lowering reimbursements for other outpatient services and ancillary care that hospitals provide.
A relatively low eligibility threshold (about $350/day in 2026) could subject many treatments to carve-out, increasing administrative burden on hospitals and CMS to track, price, and process separate claims.
Based on analysis of 2 sections of legislative text.
Creates a new rule requiring Medicare to pay separately for certain high-cost cancer drugs and biologics furnished in hospital outpatient departments (OPDs) rather than including them in the bundled OPD payment. Drugs whose estimated mean per day product cost meets or exceeds a statutory threshold ($350 per day in 2026, then indexed) will be billed and reimbursed separately using Average Sales Price (ASP) or fallback price measures, with budget‑neutral adjustments so total program spending under the rule stays constant. Defines which drugs qualify (FDA approval on/after Jan 1, 2008; not already receiving transitional pass-through payments) and specifies pricing methodologies (ASP, or WAC, or mean unit cost from claims) and that the Secretary must implement budget‑neutrality adjustments to offset payment changes. The separate payment policy takes effect for items furnished beginning in 2026.