H.R. 3164, Main Street Pharmacy Access Act

Bill Summary

H.R. 3164 would allow pharmacists to bill Medicare under Part B (Medical Insurance) for clinical services involving evaluation and management of certain conditions. Under current law, Medicare Part B pays for those services only when they are provided by a physician or other recognized clinician. The bill also would rescind $2 billion in funding for the Medicare Improvement Fund.

Estimated Federal Cost

The estimated budgetary effects of H.R. 3164 are shown in Table 1. The costs of the legislation fall within budget function 570 (Medicare).

Basis of Estimate

For this estimate, CBO assumes that the bill will be enacted early in fiscal year 2027 and that the budgetary effects will begin in calendar year 2028.

Direct Spending

CBO estimates that enacting H.R. 3164 would increase net direct spending by $587 million over the 2026-2036 period (see Table 2).

Pharmacists’ Services. Under current law, Medicare does not pay pharmacists for clinical services, such as diagnosis or treatment, that typically are provided by physicians. H.R. 3164 would allow pharmacists to bill Medicare Part B to provide evaluation and management of COVID-19, influenza, respiratory syncytial virus (RSV), and streptococcal pharyngitis (strep throat). Based on administrative data from the Centers for Medicare & Medicaid Services (CMS), information from the Medicare Payment Advisory Commission, time-and-motion studies of pharmacists, information from the private sector, and internal analyses that identified the costs of providing similar services, CBO estimates that enacting the provision would increase outlays for Medicare fee-for-service (FFS) by $1.4 billion over the 2026‑2036 period.

CBO estimates that currently about 20 percent of Medicare enrollees cannot schedule evaluations for the conditions that would be covered under the bill, and a smaller share cannot schedule vaccinations. H.R. 3164 would allow pharmacists to provide services to meet that demand. In addition, CBO expects that some enrollees who visit pharmacies to fill prescriptions would receive evaluations, tests, or vaccinations that they would not otherwise have received.

Because pharmacists’ authority to supply and bill for services is governed by state law, CBO anticipates that states would expand their scope-of-practice rules for pharmacists over the 2026-2036 period, resulting in increased Medicare spending.

The estimated increase in spending would be partially offset because CBO anticipates that under the bill Medicare would shift some spending from physician payments to pharmacist payments, which would be based on Medicare’s physician fee schedule but at a lower rate than for equivalent services. CBO expects that pharmacists would use lower-complexity billing codes than those used by physicians. In addition, CBO estimates that enacting the bill would increase vaccination rates, thus preventing or reducing the severity of some illnesses, so CBO expects that Medicare’s spending for hospitalizations would decline to offset most of the added spending for vaccines and their administration.

The estimated increase in spending also would increase payments to Medicare Advantage plans and collections of Part B premiums. Under current law, CMS sets benchmark rates for payments to Medicare Advantage plans using estimated per capita spending for FFS Medicare. CBO estimates that the increase in Medicare Advantage spending would be 1.4 to 1.7 times the annual FFS increase. Part B premiums fund roughly one-quarter of both FFS and Medicare Advantage costs. As a result, CBO estimates that additional premium collections would offset about one-quarter of the increase in FFS and Medicare Advantage spending. After accounting for those interactions, CBO estimates that enacting the pharmacist provision would increase direct spending by $2.6 billion over the 2026-2036 period.

Medicare Improvement Fund. H.R. 3164 would rescind $2.1 billion in funding for the Medicare Improvement Fund.[1] Under current law, that fund can be used to improve Medicare’s FFS program. The reduction would decrease direct spending by $2.1 billion over the 2026-2036 period.

Spending Subject to Appropriation

Based on the costs of similar activities, CBO estimates that issuing regulations under H.R. 3164 would cost less than $500,000 over the 2026-2031 period. Any related spending would be subject to the availability of appropriated funds.

Uncertainty

CBO’s estimate for H.R. 3164 is subject to uncertainty in several areas: There is limited information on which to project how many services pharmacists actually would charge Medicare, how much spending would be offset by a decline in hospitalizations, or how quickly states would revise their rules for services pharmacists can provide.

Pay-As-You-Go Considerations

The Statutory Pay-As-You-Go Act of 2010 establishes budget-reporting and enforcement procedures for legislation affecting direct spending or revenues. The net changes in outlays that are subject to those pay-as-you-go procedures are shown in Table 1.

Increase in Long-Term Net Direct Spending and Deficits

CBO estimates that enacting H.R. 3164 would increase net direct spending by more than $2.5 billion in any of the four consecutive 10-year periods beginning in 2037.

CBO estimates that enacting H.R. 3164 would increase on‑budget deficits by more than $5 billion in any of the four consecutive 10-year periods beginning in 2037.

Mandates

The bill contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act.

Estimate Prepared By

Federal Costs: Hudson Osgood

Mandates: Andrew Laughlin

Estimate Reviewed By

Sarah Sajewski
Chief, Health Systems and Medicare Cost Estimates Unit

Kathleen FitzGerald
Chief, Public and Private Mandates Unit

Chad Chirico 
Director of Budget Analysis

Estimate Approved By