New Rules for the Centers for Medicare and Medicaid Services on CAR T Therapy

The Centers for Medicare and Medicaid Services (CMS) recently approved new rules for the use of CAR T treatment for Medicare and Medicaid payments which will help more myeloma and blood cancer patients receive this key immunotherapy. 

Prior to these rules, a billing category did not exist for CMS patients receiving CAR T therapy and doctors had to "borrow" a payment category from stem cell transplant. Using the borrowed code, providers could lose more than $100,000 when administering CAR-T to Medicare patients. This was a temporary fix in order to allow CMS patients to receive CAR T treatment. With the new rules, a new inpatient payment category (called a DRG) now exists, which is a step in the right direction for more widespread use of CAR T. This is particularly important for myeloma patients as many myeloma patients are on Medicare or Medicaid.

The creation of a new DRG is an important step to ensuring that Medicare providers are appropriately and sustainably reimbursed for administering CAR-T therapies. CMS has signaled that they are committed to providing patient access to these innovative therapies. CAR-T therapies provide an unprecedented therapeutic benefit to patients with severe blood cancers.

According to the announcement: 

CMS is proposing a separate new hospital payment category for Chimeric Antigen Receptor (CAR) T-cell therapy. CAR-T is the first-ever gene therapy, and uses a patient’s own genetically modified immune cells to treat people with certain types of cancer, instead of additional chemotherapy or other types of treatment paid for under the IPPS. Currently, CAR-T hospital cases are paid at the same rate as bone marrow transplants and qualify for additional payments through the temporary new technology add-on payment for high cost cases that’s set to expire this year. The new inpatient hospital payment category, or the Medicare Severity Diagnostic Related Group (MS-DRG), for CAR-T will provide a predictable payment rate for hospitals administering the therapy. This is another example of CMS’s commitment to ensuring that beneficiaries have access to the latest medical innovation and to removing barriers to medical innovation across our healthcare system.

With the new DRG, CMS will pay $239,490 for administration of CAR T therapy, the highest payment for a DRG surpassing heart transplant. 

Additional rules were set for new antimicrobials, which are antibiotics to treat drug-resistant infections and a 2.7% payment increase (3.5 Billion) to providers for CMS services. According to the agency:

CMS is taking action to protect the health and safety of our nation’s patients and providers in the wake of the COVID-19 outbreak. Following President Trump’s declaration of a national emergency, CMS has announced aggressive actions and regulatory flexibilities to help healthcare providers and states respond to and contain the spread of COVID-19. 

To read a background fact sheet on the new rules, click here.