CMS finalizes lower patient costs for outpatient drugs, scans

Clinical takeaway: Consider telling patients that imaging without contrast at excepted off-campus hospital departments (other than rural sole community hospitals) should carry smaller copays in 2027, since Medicare will pay the office rate. Drug savings reach only patients who receive a 340B drug in a hospital outpatient department. 

Medicare patients owe a share of whatever Medicare allows, so the site a clinician chooses for a scan or a drug administration can change the bill without changing the care. CMS has narrowed that difference one service at a time, first for clinic visits in 2019 and then for drug administration in the 2026 rule. 

Drugs purchased through the 340B discount program carried their own version of the problem. A CMS survey found wide differences between what hospitals paid for 340B drugs and for other drugs, and in some cases the coinsurance alone exceeded the hospital's acquisition cost. The final 2027 rule extends office-rate payment to imaging and ties 340B drug payment to hospitals' acquisition costs.

CMS estimates that a Medicare beneficiary who receives a qualifying 340B drug in a hospital outpatient department will save an average of $900 in 2027. Payment for those drugs falls to average sales price minus 28%, a rate derived from hospitals' acquisition costs rather than office-based payment rates. CMS projects the change will reduce beneficiary drug spending by $1.1 billion in the first year. Because the law requires budget neutrality, payments for non-drug outpatient services will increase to offset the drug payment reduction.

Imaging without contrast, including bone density scans, x-rays, ultrasounds, CT scans, and MRIs, will be paid at the physician office rate when performed at excepted off-campus hospital departments. CMS expects beneficiary cost-sharing to fall by about $70 million in 2027, a system-wide reduction rather than a per-scan savings amount. Rural sole community hospitals are exempt.

The rule also removes 637 services from the inpatient-only list in the second year of a three-year phase-out, a change that CMS says could lower out-of-pocket costs, although it did not quantify the effect. Eight additional botulinum toxin injection codes will require prior authorization in hospital outpatient departments.

CMS plans to finish eliminating the inpatient-only list in a third year, which will allow more procedures to be performed in the outpatient setting. 

Source: Centers for Medicare & Medicaid Services (2026 Nov 4). Medicare Outpatient Final Rule Expands Surgical Options, Lowers Out-of-Pocket Costs for 340B Drugs