Text sizeBackground

Patient Resources › Medicare and your medication › Where you get infused

Where you get infused changes the bill

The same medicine, the same dose, the same nurse — and a bill that can be several times larger, decided by how the building is registered with Medicare.

The short answer

Medicare pays two completely different rates for an infusion depending on whether the place you sit is billed as a hospital outpatient department or as a doctor’s office. By Medicare’s own arithmetic, the office rate for giving an infusion is only about a quarter to a third of the hospital rate. The hospital rate is roughly three to four times higher for the identical service.

You pay 20% of whichever number applies. So the setting does not just change what Medicare spends. It changes what you owe, every single infusion, for as long as you are on the drug.

Nothing about your medical care is different. This is a billing category, and most people never find out it exists until the first bill arrives.

Why does the hospital cost more for the same infusion?

Because a hospital bills for the room as well as the care.

  • In a doctor’s office, there is one bill. Medicare pays a set amount for giving the infusion and a set amount for the drug itself.
  • In a hospital outpatient department, there are two bills — one from the doctor and one from the hospital, called a facility fee. The facility fee is meant to cover the building, the equipment and the overhead. Each bill carries its own 20%.

Independent analysis of Medicare claims found hospital outpatient departments being paid roughly two to three times the office rate for the same drug administration. Medicare’s own advisory commission has been telling Congress for years that this gap has no clinical justification, and that it has pushed infusions out of offices and into hospitals — between 2015 and 2021 the volume of chemotherapy administration fell 14% in offices and rose 21% in hospital outpatient departments.

Why did my costs go up when nothing changed?

If your infusion suddenly costs more and you are in the same chair with the same nurse, there is a specific and very common explanation: a hospital bought the practice.

This is called provider-based billing. Nothing physical has to change. The clinic is re-registered as a department of the hospital, and from that day the same visit generates a hospital facility bill on top of the doctor’s bill. Same room, same people, two bills.

Are you entitled to be warned? Partly, and the gap is worth knowing. Federal rules require written notice before your visit — telling you that you will owe a hospital coinsurance you would not otherwise owe — but only when the clinic is off the hospital’s main campus. If the department sits on the main campus, or within about 250 yards of it, there is no federal notice requirement at all.

Washington State goes further than federal law here. A provider-based clinic in Washington that charges a facility fee must tell you before non-emergency care that it is licensed as part of a hospital and that you may get a separate facility charge resulting in higher out-of-pocket costs — and it must post that same statement prominently, including on its website. If you were never told, that is worth raising.

Did the 2026 rule change fix this?

For most people, no — and this is where recent coverage is misleading, because a real change did happen and it is narrower than it sounds.

On January 1, 2026, Medicare began paying the lower office-equivalent rate for drug administration at hospital departments that sit off the main campus and had been billing before November 2015. CMS estimated it would save patients about $70 million a year in coinsurance.

But infusions given on a hospital’s main campus were not included, and about seven-eighths of Medicare’s hospital outpatient spending happens on main campuses. So if you are infused at the hospital itself, the 2026 change does not reach you. The proposed rule for 2027 extends this idea to some imaging, not to more drug administration.

The hospital bill nobody warns you about

This one is worth reading even if the rest of the page does not apply to you, because it arrives with no warning and looks like a mistake.

Medicare Part B does not pay for drugs it considers “usually self-administered” when they are given in a hospital outpatient setting. Each region’s Medicare contractor keeps its own list of which drugs those are. If something you were given is on that list, the hospital bills you directly — at the hospital’s own charges, which are not the Medicare rate.

Here is why it blindsides people. When Medicare denies something as not medically necessary, you have to be warned in advance and asked to sign. This is a different kind of denial — the drug is simply outside the benefit — so no advance notice is required and none is given. The first you hear of it is the bill.

The pattern in rheumatology is that the self-injected versions appear on these lists while the infused versions do not. In our region the list includes methotrexate auto-injectors, adalimumab, etanercept, the abatacept and golimumab self-injections, secukinumab, ustekinumab, anakinra and others. Lists differ by region and are revised several times a year.

What to do about it:

  • Ask before, not after. “Is anything I am getting on the Medicare self-administered drug list?” If the answer is yes, ask whether you can bring your own from your pharmacy instead.
  • Try your drug plan. Your Part D plan may cover it. You may have to pay first and submit for reimbursement, and you can request an exception if it is not on the formulary.
  • Do not just pay a chargemaster bill. If the hospital is a nonprofit, it is required to have a written financial assistance policy, to publicize it, and — if you qualify — to charge you no more than the amount generally billed to insured patients rather than its list price. That applies to people on Medicare too. Ask for the policy and the application by name.

Patient advocates asked Medicare to fix the lack of notice here in 2023. As of this writing, the policy has not changed.

Can my plan make me move somewhere else?

Original Medicare cannot. You have a statutory right to obtain services from any qualified provider, and the short list of hospital outpatient services that require advance approval under Original Medicare does not include drug administration or any infused biologic. Nobody can redirect you.

This is mostly a commercial insurance practice, and that is good news if you are on Medicare. Insurers run what they call “site of care” review, which approves an infusion at a hospital only when specific conditions are met and otherwise directs you somewhere cheaper. Nearly every such policy published in writing applies to employer and individual commercial plans — and several say plainly that they do not apply to Medicare Advantage.

So if you are on Medicare Advantage, you are less likely to run into this than someone on commercial insurance. Less likely is not never. One large insurer’s policy says it may also be applied to Medicare Advantage in certain instances, and that policy caps ongoing hospital-based infusion at six months before requiring reassessment, after which you are expected to move. The only way to know is to ask your own plan.

If it does apply, there are exceptions, and they are written down. Plan policies generally allow you to stay at a hospital site when at least one of these is documented — and these are the words to use:

  • It is your first infusion, or your first after a break of six months or more
  • You have had a severe or potentially life-threatening reaction to an infusion before
  • You are medically unstable, or have a heart, lung or kidney condition that means you could need services only a hospital has
  • You have difficult vein access
  • A physical or cognitive impairment makes another setting unsafe for you
  • There is no suitable alternative you can actually get to

If one of those is true of you, say so to your doctor’s office and ask them to document it in the request. A plan is far more likely to approve an exception that names its own criteria than a letter that argues generally.

And if you are turned down, appeal. In 2025, Medicare Advantage plans denied about 12% of standard prior authorization requests — and 67% of denied requests were overturned when someone appealed.

What to ask, and when

Almost all of the damage here is preventable with four questions asked before the first infusion at a new place — or as soon as you hear your practice has been bought.

  1. “Is this billed as a hospital outpatient department or as a doctor’s office?” This one question determines most of the bill.
  2. “Will I get one bill or two?” Two means there is a facility fee, and you owe 20% of that as well.
  3. “Is anything I am receiving on the Medicare self-administered drug list?” Ask the infusion pharmacy or your rheumatologist’s office, not the front desk.
  4. “Does my authorization say where I can be infused, and when does it run out?” Ask your plan if you have Medicare Advantage. An authorization is often permission to be infused at a named place, and moving can require a new one. An infusion given under an authorization that names the wrong location can be denied afterwards.

Can I get a price before I agree to it?

Partly, and there is a widely repeated claim here that is wrong, so it is worth being precise.

  • The “good faith estimate” you may have read about does not apply to you. That right comes from the No Surprises Act, and it explicitly does not cover people on Medicare, Medicaid, VA or TRICARE. The equivalent protection for insured patients has not been implemented. Do not spend a week trying to invoke it.
  • Hospital price transparency is real and enforceable. Every hospital must publish its prices and must offer either a list of shoppable services or an online price estimator tool, free and prominently displayed. The estimator is the practical route. Ask the billing office where it is, and ask for an estimate for the infusion codes plus the drug.
  • Medicare has no tool that compares a hospital to a doctor’s office for an infusion. That absence is worth naming. The comparison you most want to make is the one nobody has built.

Free help

Related

Where these figures come from

  1. Physician office infusions are paid under the Medicare Physician Fee Schedule and hospital outpatient infusions under the Outpatient Prospective Payment System, with a separate facility charge. Part B drugs are generally paid at the average sales price plus 6% — Social Security Act §1847A; CMS, “Part B Drug Payment Limits Overview,” March 2026.
  2. CMS calculated that the volume-weighted Physician Fee Schedule payment for the drug administration payment groups was 24% to 33% of the outpatient payment — cited in Adler L and Fiedler M, Brookings Institution, comment on the CY2026 OPPS proposed rule, September 22, 2025.
  3. Hospital outpatient departments paid approximately 200% to 300% of the physician office rate for the same drug administration, using the 2021 Medicare 5% Limited Data Set — Actuarial Research Corporation, October 18, 2023.
  4. Chemotherapy administration volume fell 14.2% in freestanding clinician offices and rose 21.0% in hospital outpatient departments between 2015 and 2021 — Medicare Payment Advisory Commission, Report to the Congress, June 2023, Chapter 8.
  5. Written notice of potential facility-fee liability is required before services at an off-campus provider-based department — 42 CFR §413.65(g)(7). “Campus” is defined as the main buildings and areas within 250 yards — 42 CFR §413.65(a)(2). There is no equivalent federal notice requirement for on-campus departments.
  6. Washington State requires provider-based clinics charging a facility fee to give notice before non-emergency services and to post the same statement prominently, including on the clinic’s website — RCW 70.01.040.
  7. Drug administration in excepted off-campus provider-based departments is paid at the Physician Fee Schedule equivalent rate effective January 1, 2026, with an estimated $70 million in reduced beneficiary coinsurance — CMS, CY2026 Hospital Outpatient Prospective Payment System final rule (CMS-1834-FC), 90 Fed. Reg., November 25, 2025, and CMS fact sheet, November 21, 2025. Rural sole community hospitals are exempt. On-campus hospital outpatient departments are not included.
  8. 87.4% of Medicare hospital outpatient spending occurred at on-campus hospital outpatient departments in 2022 — Avalere Health, January 10, 2024.
  9. Medicare Part B does not cover drugs usually self-administered by the patient — Social Security Act §1861(s)(2), as amended by §112 of the Benefits Improvement and Protection Act of 2000; CMS Medicare Benefit Policy Manual, Chapter 15, §50.2. “Usually” means more than 50% of the time across all Medicare beneficiaries using the drug.
  10. Because this is a benefit category denial rather than a medical necessity denial, an Advance Beneficiary Notice is not required and the provider may charge the beneficiary — Noridian Healthcare Solutions, Self-Administered Drug Exclusion List, article A53033, current revision effective August 29, 2026. Washington is in Noridian Jurisdiction F. Lists are maintained separately by each Medicare Administrative Contractor and differ by region.
  11. Coverage of self-administered drugs through a Part D plan, including paying up front and submitting for reimbursement and requesting a formulary exception — CMS, “How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings,” Product No. 11333.
  12. Nonprofit hospitals must maintain and widely publicize a written financial assistance policy covering all medically necessary care, and may not charge a person eligible under it more than the amount generally billed to insured patients — Internal Revenue Code §501(r)(4) and §501(r)(5). This applies to Medicare beneficiaries; it does not apply to for-profit or government hospitals.
  13. Medicare beneficiaries have a statutory right to obtain services from any qualified provider — 42 U.S.C. §1395a(a). The hospital outpatient services requiring prior authorization under Original Medicare are an enumerated list that does not include drug administration — 42 CFR §419.83. The 2026 WISeR pilot covers thirteen procedures and devices and no medications.
  14. Site-of-care policies limiting hospital-based infusion, including a six-month duration limit before reassessment and the clinical exception criteria quoted here — UnitedHealthcare, “Provider Administered Drugs — Site of Care,” effective September 1, 2026, which states it may also be applied to Medicare Advantage plans in certain instances; Cigna Coverage Policy 1605, effective June 15, 2026; Anthem/Elevance Clinical UM Guideline CG-MED-83. Several published site-of-care policies, including Regence dru408 and Kaiser Permanente Washington’s, state that they do not apply to Medicare plans. Site-of-care review is predominantly a commercial insurance practice; application to Medicare Advantage varies by plan and is less common.
  15. Medicare Advantage plans denied 12% of standard and 10% of expedited prior authorization requests in 2025, and 67% of denied requests were overturned on appeal — KFF analysis of CMS prior authorization transparency data, August 13, 2026.
  16. No Surprises Act good faith estimate requirements do not apply to people enrolled in Medicare, Medicaid, Indian Health Services, Veterans Affairs health care or TRICARE — CMS, Good Faith Estimate and Patient-Provider Dispute Resolution guidance. The advanced explanation of benefits for insured patients remains unimplemented.
  17. Hospitals must publish standard charges and must provide either a consumer-friendly list of at least 300 shoppable services or an internet-based price estimator tool, free and prominently displayed — 45 CFR §§180.50, 180.60. Additional requirements took effect January 1, 2026, with enforcement from April 1, 2026 — CMS fact sheet, CY2026 hospital price transparency policy changes.

About this page

Written and reviewed by Alison Bays, MD, MPH, board-certified rheumatologist. Figures are current for 2026 and were last checked in September 2026.

This is educational information, not advice — not medical, legal, financial or insurance advice, and not a substitute for talking to your doctor, your plan, or the hospital’s billing office. Nothing is sold here. No insurance is sold here, no plan, hospital or infusion provider is recommended, and neither this page nor its author is paid by any insurance company, plan, hospital, pharmaceutical manufacturer or broker. This page is not affiliated with, endorsed by, or connected to Medicare, the Centers for Medicare & Medicaid Services, or any government agency.

Found something wrong? Please tell us.