Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: November 01, 2019

OPPS and ASC Temporary Increase in Medicare Part B Payment for Certain Biosimilar Biological Products

Section 11403 of the Inflation Reduction Act of 2022 (IRA) temporarily increases payment for certain biosimilar biological products that are calculated using the Medicare Average Sales Price Payment Methodology from average sales price (ASP) plus 6 percent to ASP plus 8 percent of the ASP of the reference biological. The increase applies for a 5-year period defined in the statute. For qualifying biosimilar biological products for which payment was made using ASP as of September 30, 2022, the 5-year period begins on October 1, 2022. For qualifying biosimilar biological products for which payment is first made using ASP between October 1, 2022, through December 31, 2027, the 5-year period begins on the first day of the calendar quarter during which such payment is first made. A qualifying biosimilar biological product is defined as a biosimilar with an ASP that is not more than the ASP of the reference biological.

The Outpatient Prospective and Ambulatory Surgical Center payment systems generally use the Medicare Average Sales Price Payment Methodology for biosimilars. Therefore, in accordance with section 11403 of the IRA, the OPPS and ASC addenda files will reflect the temporary increased amount for qualifying biosimilar biological products beginning with the October 2022 file.

ASC Covered Procedures List (CPL) Nomination Process for CY 2023

• Information related to this process (PDF) is now available.
• For questions, concerns, suggestions, or inquiries regarding the ASC CPL, please consider contacting CMS by email at ASCPPS@cms.hhs.gov

Value Based Purchasing Program for Ambulatory Surgical Centers

The Affordable Care Act requires the Secretary of Health and Human Services to develop a plan to implement a value-based purchasing (VBP) program for payments under the Medicare program for ambulatory surgical centers (ASCs). The Secretary submits a report to Congress containing this plan.

The Report to Congress (PDF) describes the current efforts to improve quality and payment efficiency in ASCs.  In addition, it considers the steps required in designing and implementing an ASC VBP program for payments under the Medicare program.  CMS views VBP as an important step forward in revamping how Medicare pays for health care services; moving the program towards rewarding better value, outcomes, and innovations, instead of merely volume.

The ASC VBP Report to Congress was authorized under Section 3006(f) of the Patient Protection and Affordable Care Act (Pub. L. 111-148), enacted on March 23, 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), enacted on March 30, 2010 (collectively known as the Affordable Care Act) (as added by section 10301(a) of the Affordable Care Act).

Ambulatory Surgical Center (ASC) Approved HCPCS Codes and Payment Rates

These files contain the procedure codes which may be performed in an ASC under the Medicare program as well as the ASC payment group assigned to each of the procedure codes. The ASC payment group determines the amount that Medicare pays for facility services furnished in connection with a covered procedure.  For 2000 - 2006 files, go to the ASC Payment Rates Archive page (see the Left column).
Note: These files contain material copyrighted by the American Medical Association.

ASC CENTER

For a one-stop resource for Medicare Fee-for-Service (FFS) ambulatory surgical centers, visit the Ambulatory Surgical Centers (ASC) Center page.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.