Pharmacy and Medically Underserved Areas Enhancement Act
The Pharmacy and Medically Underserved Areas Enhancement Act seeks to expand Medicare coverage to include certain pharmacist services. It would add pharmacist-provided services to the list of Medicare Part B benefits, but only when the pharmacist is licensed by the state and the service is legally authorized in that state. The covered services must be the type that would be covered if provided by a physician or as an incidental service to a physician. Coverage would apply only in health professional shortage areas, medically underserved areas, or medically underserved populations. Payment would be 80% of the lesser of the actual charge or 85% of the physician’s fee schedule amount, with new pharmacist-specific billing codes to be developed. The amendments would take effect for services furnished on or after January 1, 2027.
Key Points
- 1Coverage expansion: Medicare Part B would cover pharmacist services furnished by a licensed pharmacist when the service falls within the same scope as a physician-provided or physician-incident-to service and occurs in designated underserved areas or populations.
- 2State licensing and scope: The pharmacist must be licensed by the state and the service must be legally authorized to be performed in the state where the service occurs.
- 3Location and population criteria: Services must be provided in a health professional shortage area (HPSA), a medically underserved area (MUA), or a medically underserved population (MUP).
- 4Payment methodology: For pharmacist services, Medicare would pay 80% of the lesser of the actual charge or 85% of the physician fee schedule amount that would apply if a physician provided the service.
- 5Implementation details: The Secretary of Health and Human Services must create pharmacist-specific billing codes under the physician fee schedule, and the new rules apply to services furnished on or after January 1, 2027.