Sponsors (17)
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.
The bill expands Medicare coverage to let pharmacists provide and be paid for HIV prevention services—improving access and protecting patients from surprise bills—but lower reimbursement rates, state scope‑of‑practice limits, and "reasonable and necessary" coverage rules may limit provider participation and create uneven access.
Medicare beneficiaries can receive pharmacist‑provided HIV prevention services (PrEP/PEP) beginning Jan 1, 2027, increasing availability of prevention care and potentially reducing HIV transmission.
Pharmacists are authorized and reimbursed to provide evaluation, testing, counseling, and medication administration for HIV prevention, reducing barriers and speeding delivery of care for beneficiaries.
Medicare beneficiaries are protected from balance billing for these pharmacist services, so patients are less likely to face surprise charges.
Pharmacists may receive lower payment rates (capped at 80% of a reduced physician‑based amount), which could discourage some pharmacists from furnishing services and reduce provider availability, especially in low‑margin or rural areas.
Beneficiaries in states with restrictive scope‑of‑practice laws may see little benefit because pharmacists' authority to furnish covered services depends on state law, producing uneven access across states.
Limiting coverage to services that are "reasonable and necessary" for prevention/detection could lead to claim denials or administrative disputes over whether specific pharmacist services qualify, delaying or blocking access.
Based on analysis of 2 sections of legislative text.
Adds pharmacist‑provided HIV prevention services to Medicare Part B, sets payment and billing rules, and bans balance billing, effective Jan 1, 2027.
Introduced January 21, 2026 by Mark Pocan · Last progress January 21, 2026
Adds pharmacist‑provided HIV prevention services to Medicare Part B coverage, including evaluation, screening, counseling, medication administration, and related lab tests when pharmacists are authorized under State law to provide them. Sets a payment rule (Medicare pays 80% of the lesser of the pharmacist’s actual charge or 85% of the physician payment rate), bans balance billing for these pharmacist services, and excludes services that are not reasonable and necessary for HIV prevention or detection. The coverage changes apply to items and services furnished on or after January 1, 2027. The law creates a new statutory benefit category for pharmacist HIV prevention services, adjusts payment and beneficiary billing protections, and limits coverage to reasonable and necessary services for HIV prevention and detection.