Sponsors (22)
The bill expands Medicare access to pharmacist‑provided HIV prevention services and protects beneficiaries from surprise charges, but does so with relatively constrained reimbursement, state‑dependent scope limits, and potential coverage disputes that could limit uptake.
Medicare beneficiaries can receive pharmacist‑provided HIV prevention services (PrEP/PEP) and associated evaluation, testing, counseling, and medication administration beginning Jan 1, 2027, increasing timely access to prevention care.
Medicare patients are protected from balance billing for pharmacist‑provided HIV prevention services, reducing the risk of surprise charges.
Pharmacists and CMS get a clear payment framework (payment set as 80% of the lesser of the charge or 85% of the physician fee), which may encourage pharmacist participation and simplify billing.
Medicare beneficiaries and pharmacists may face reduced access if pharmacist payment rates are relatively low (capped at 80% of a reduced physician‑based amount), which could discourage pharmacists from furnishing services in some areas.
Beneficiaries in states with restrictive scope‑of‑practice laws may see little or no benefit because pharmacists' authority to furnish covered services depends on State law.
Limiting coverage to services judged 'reasonable and necessary' for prevention or detection could lead to claim denials or administrative disputes over whether specific pharmacist services are covered.
Based on analysis of 2 sections of legislative text.
Adds Medicare Part B coverage and payment rules for pharmacist‑provided HIV prevention services, bans balance billing, effective Jan 1, 2027.
Official title: To amend title XVIII of the Social Security Act to provide coverage for certain HIV prevention services furnished by pharmacists under the Medicare program.
Introduced January 21, 2026 by Mark Pocan · Last progress January 21, 2026
Adds pharmacist‑provided HIV prevention services to Medicare Part B coverage and payment rules, prohibits balance billing for those services, and excludes non‑reasonable or unnecessary services. Applies to items and services furnished on or after January 1, 2027. Defines the covered pharmacist services (evaluation, management, screening, consultation, counseling, medication administration, and related lab tests), sets a payment formula (Medicare pays 80% of the lesser of the pharmacist’s actual charge or 85% of the physician-based amount), and clarifies that services not reasonable and necessary for HIV prevention are excluded from coverage.