Clinical Laboratory Fee Schedule Based on Protecting Access to Medicare Act

20.3 – Clinical Laboratory Fee Schedule Based on Protecting Access to Medicare Act (PAMA) of 2014 (Rev. 4479; Issued: 12-20-19 Effective: 01-23-20, Implementation: 01-23-20) Effective January 1, 2018, CLFS rates were based on weighted median private payer rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. Fee Schedule Through December 31, 2017 Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833 (h) of the Social Security Act. Payment is lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees. Co-payments and deductibles do not apply to services paid under the Medicare clinical laboratory fee schedule. Each year, new laboratory test codes are added to the clinical laboratory fee schedule and corresponding fees are developed in response to a public comment process. Also, for a cervical or vaginal smear test (pap smear), the fee cannot be less than a national minimum payment amount, initially established at $14.60 and updated each year for inflation. Sole Community Hospitals Effective for hospital outpatient tests furnished by a hospital on or after April 1, 1988 through December 31, 2017, to receive the 62 percent fee the hospital must be a sole community hospital. Effective for hospital outpatient tests furnished by a Sole community possessive hospital’s payment is based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. Critical Access Hospitals Critical access hospitals are generally paid for outpatient laboratory tests on a reasonable cost basis, instead of by the fee schedule, as long as the lab service is provided to a CAH outpatient.