HR7189-119

What This Bill Does

The PrEP Access Act expands Medicare Part B to cover pharmacist-provided HIV prevention services. Covered services are those a pharmacist is legally authorized to furnish under State law and that would otherwise be covered if provided by a physician or incident to a physician service. The covered category includes evaluation, management, screening, consultation, and counseling related to pre-exposure prophylaxis, post-exposure prophylaxis, other evidence-based HIV prevention interventions, medication administration for those interventions, and related clinical diagnostic laboratory tests. Medicare payment is set at 80 percent of the lesser of the actual charge or 85 percent of the physician-fee-schedule payment basis. The bill updates practitioner billing provisions to include pharmacists and adds a reasonable-and-necessary limit for pharmacist-provided HIV prevention services. The amendments apply to items and services furnished on or after January 1, 2027.

Who Benefits and How

Medicare beneficiaries seeking HIV prevention, people who need PrEP or PEP access, pharmacists authorized under State law, pharmacies, HIV prevention programs, and public health clinics benefit because Medicare would pay for pharmacist-furnished prevention services that can be easier to access than physician offices. Beneficiaries may gain access to medication administration, counseling, screening, and related lab testing through pharmacies. Pharmacists and pharmacies gain a new Medicare-covered service category.

Who Bears the Burden and How

CMS, Medicare Administrative Contractors, pharmacists, pharmacies, and billing compliance staff must implement new Part B coverage, payment, reasonable-and-necessary determinations, state-scope checks, claims processing, and documentation for HIV prevention services beginning January 1, 2027. Federal taxpayers and Medicare Part B finances bear the cost of new covered services. Physicians may see some HIV prevention service volume shift to pharmacists.

Key Provisions

• Adds pharmacist-provided HIV prevention services to Medicare Part B.
• Covers pharmacist-furnished evaluation, management, screening, consultation, counseling, medication administration, and related laboratory testing.
• Limits coverage to services pharmacists are legally authorized to furnish under State law.
• Includes PrEP, PEP, and other evidence-based HIV prevention interventions.
• Sets payment at 80 percent of the lesser of actual charges or 85 percent of the physician-fee-schedule amount.
• Applies the amendments to items and services furnished on or after January 1, 2027.