Capitol Correspondence - 04.29.19

In Break from Cost-Saving Focus, CMS Seeks to Increase CAR-T, Breakthrough Devices Rates

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ANCOR is sharing this article by Politico Pro because of our interest in the adoption of new technologies by the Centers for Medicare and Medicaid Services (CMS). Technology holds a lot of promises for Medicaid-funded supports for people with disabilities, but state regulations have not kept up with it. As CMS develops its interest in adopting new technologies, ANCOR is monitoring to see what precedent this could set for disability supports.

As shared by Politico Pro:

“CMS is proposing to raise the reimbursement rate for the novel cancer cell therapy treatment CAR-T by nearly $56,000 in fiscal 2020 as part of a broader increase in payment rates for new technology.

Overall, the new technology add-on payment will rise from 50 percent of the costs of the technology to 65 percent. Add-on payments are meant to protect hospitals from losses that can occur from utilizing new innovations. CMS estimates this change will cost $110 million in 2020.

The change outlined in Medicare’s proposed hospital inpatient rule today would mean Gilead’s CAR-T Yescarta and Novartis’ CAR-T Kymriah would be eligible for a nearly $243,000 add-on payment. The list price of the treatments can be close to half a million dollars, not including associated costs.

CMS declined to create a new Medicare severity diagnosis-related group (MS-DRG) specifically for CAR-T for 2020 despite arguments the designation is necessary to ensure providers won’t suffer financial losses.


For medical devices, CMS is proposing to allow all approved medical devices granted breakthrough status by FDA to receive an add-on payment beginning in fiscal 2021 as long as the device meets the cost criterion to receive the payment.”