CMS FY 2020 Rule Increases Reimbursment for CAR-T Therapies from 50% to 65%
CMS FY 2020 Rule Significantly Increases Reimbursement for CAR-T Therapies
The latest FY2020 rule from CMS recognizes the significant clinical improvement offered by KYMRIAH® and YESCARTA®
CMS raised the reimbursement limit for CAR-T therapies from 50% to 65% of the average cost of the technology
In 2020, CAR-T therapies will be reimbursed at $242,450
The total cost on CMS is estimated to be $93,585,700 for 386 patients
Notable Quotes from the FY2020 Rule for CAR-T Therapies
"we stated in the proposed rule that given the relative newness of CAR T-cell therapy and our proposal to continue new technology add-on payments for FY 2020 for the two CAR T-cell therapies that currently have FDA approval (KYMRIAH™ and YESCARTA™), as discussed in section II.G.4.d. of the preamble of the proposed rule and this final rule, at this time we believe it may be premature to consider creation of a new MS-DRG specifically for cases involving CAR T-cell therapy for FY 2020"
"After evaluation of the newness, costs, and substantial clinical improvement criteria for new technology add-on payments for KYMRIAH® and YESCARTA® and consideration of the public comments we received in response to the FY 2019 IPPS/LTCH PPS proposed rule, we approved new technology add-on payments for KYMRIAH® and YESCARTA® for FY 2019 (83 FR 41299). Cases involving KYMRIAH® or YESCARTA® that are eligible for new technology add-on payments are identified by ICD-10–PCS procedure codes XW033C3 or XW043C3. The applicants for both KYMRIAH® and YESCARTA® estimated that the average cost for an administered dose of KYMRIAH® or YESCARTA® is $373,000. Under existing § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology or 50 percent of the costs in excess of the MS–DRG payment for the case. As a result, for FY 2019, the maximum new technology add-on payment for a case involving the use of KYMRIAH® or YESCARTA® is $186,500"
"In addition, under the proposed change to the calculation of the new technology add-on payment amount discussed in section II.H.9. of the preamble of the proposed rule (84 FR 19373), we proposed that the maximum new technology add-on payment amount for a case involving the use of KYMRIAH® and YESCARTA® would be increased to $242,450 for FY 2020"
"Under the revised calculation of the new technology add-on payment amount discussed in section II.H.9. of the preamble of this final rule, the maximum new technology add-on payment amount for a case involving the use of KYMRIAH® and YESCARTA® will be $242,450 for FY 2020; that is, 65 percent of the average cost of the technology"
"Based on both applicants’ estimates of the average cost for an administered dose for FY 2019, we currently estimate that new technology add-on payments for KYMRIAH® and YESCARTA® will increase overall FY 2020 payments by $93,585,700 (maximum add-on payment of $242,450 * 386 patients)"
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