Pharmacy and Medically Underserved Areas Enhancement Act
This bill, introduced in the Senate as the Pharmacy and Medically Underserved Areas Enhancement Act (S. 2800), would expand Medicare coverage to include pharmacist services. It allows licensed pharmacists to provide these services in certain underserved settings, and treats them as services that would otherwise be covered if furnished by a physician (or incident to a physician’s service). The bill sets a specific payment framework: for pharmacist services, Medicare would pay 80% of the lesser of the actual charge or 85% of the physician fee schedule amount as if the service were provided by a physician. The changes would take effect for services furnished on or after January 1, 2027, and the Secretary of Health and Human Services would create pharmacist-specific codes under the physician fee schedule. Sponsored by Senators Grassley and Luján, the bill aims to improve access to pharmacist care in areas with physician shortages or underserved populations, by formally including pharmacists within Medicare’s covered benefits and establishing standardized reimbursement.
Key Points
- 1Coverage expansion: Pharmacist services, performed by a licensed pharmacist and within state-allowed scope, can be covered under Medicare if the service would be covered if provided by a physician or as an incident to a physician’s service, and if delivered in a health professional shortage area, medically underserved area, or medically underserved population.
- 2Eligibility criteria: The pharmacist must be licensed by state law, and the service must be legally authorized to be performed in the state where provided.
- 3Location and population targets: Coverage applies specifically to settings in health professional shortage areas (HPSAs) or medically underserved areas/populations as defined by relevant health laws.
- 4Payment formula: For pharmacist services, Medicare would pay 80% of the lesser of the actual charge or 85% of the physician fee schedule amount (as if furnished by a physician).
- 5Implementation steps: The Secretary of Health and Human Services must develop pharmacist-specific codes under the physician fee schedule to enable billing for these services.
- 6Effective date: The changes apply to services furnished on or after January 1, 2027.