Medicare Reimbursement Update for CAR-T Finalized

September 4, 2020

On September 2, the Centers for Medicare & Medicaid Services (CMS) released updates to the Inpatient Prospective Payment System (IPPS) final rule for fiscal year 2021, including updates to Medicare payment policies and payment rates for most acute care hospitals.

CMS finalized its proposal to establish a Medicare Severity Diagnosis Related Group (MS-DRG) for  chimeric antigen receptor T-cell (CAR-T) services. The national, unadjusted payment amount for this new group—MS-DRG 018—will be $239,929. That is $438 more than the payment amount from the proposed rule, but significantly less than what the Association for Clinical Oncology (ASCO) recommended in its comment letter, as well as less than the average sales price of CAR-T medicines, which is $373,000.

ASCO supported the establishment of a new MS-DRG for CAR-T, which has the potential to afford providers the reimbursement certainty they need to offer this effective, potentially life-saving therapy, and we thank CMS for recognizing this by finalizing its proposal. We remain concerned, however, that the reimbursement rate will be insufficient to cover the cost of CAR-T therapy and associated services, which could restrict access to this important treatment. The Association will continue to advocate for adequate reimbursement for cancer treatments.

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