This bill (the FAIC Act) changes how Medicare pays for some cancer drugs given in hospital outpatient departments. Starting in 2026, if a cancer drug’s estimated mean per day product cost meets or exceeds a yearly threshold ($350 in 2026), Medicare must stop packaging that drug’s payment into the bundled outpatient payment and instead pay for the drug separately. The separate payment will be the drug’s average sales price (ASP) as adjusted by the Secretary. If ASP data are not available, the Secretary will use the wholesale acquisition cost (WAC) as adjusted, or, if that is not available, the mean unit cost from hospital claims. The rule applies to drugs or biologics approved by the FDA on or after January 1, 2008, that are not receiving transitional pass-through payments and that otherwise would be packaged. The threshold after 2026 rises each year by the OPD fee schedule increase factor. The bill also requires the Secretary to make payment adjustments so total Medicare outpatient spending for the year remains budget neutral relative to not applying this rule.
No publicly available information on the bill’s net federal cost or savings. The bill requires the Secretary to adjust other payments so yearly Medicare outpatient expenditures with this change equal what they would have been without the change (a budget neutrality requirement). The bill sets the cost threshold at $350 per day for 2026 and ties later thresholds to the OPD fee schedule increase factor.
The bill’s stated purpose is to ensure equitable payment for, and preserve Medicare beneficiary access to, cancer treatments under the Medicare hospital outpatient prospective payment system.
No publicly available information.