Costs
Costs are the expenses incurred by the provider for services. Costs are converted to charges in the hospital bill for CAR T cell therapy administration. In this resource, all outpatient services or all inpatient services that are part of a single episode of care, i.e. from admission to discharge are included as costs. Costs may include cell collection and handling, cell preparation for transport, cell receipt and preparation, cell administration, and management post administration including potential adverse events. Costs can include the direct costs of patient care such as medicines and supplies, as well as indirect costs such as overhead for administrative expenses including building maintenance and equipment.
Charges
Charges reflect adjusted costs submitted by the provider to CMS or a private payer for reimbursement. This value represents the list price a provider sets for services rendered before negotiating any discounts. The charge can be - and often is - different from the actual expenses (costs) incurred and/or the amount paid.
Estimated payer reimbursement
The reimbursement amount is the total amount a provider may be paid by payers for health care services. An estimated payment amount uses the provider- and payer-specific variables, such as MS-DRG base rate and, if applicable, reimbursement for outlier costs. The reimbursed amount for certain payers depends on submitted charges, of which a Commercial payer may reimburse a specified percentage. Submitted charges may also be converted to estimated provider costs for the episode of care.
Estimated patient cost-sharing responsibility
The cost-share amount is the share of costs that the patient pays out of their own pocket. The most common forms of cost sharing are: deductibles (an amount that must be paid before most services are covered by the plan), copayments (fixed dollar amounts), and coinsurance (a percentage of the charge for services). Cost-sharing responsibility doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. The type and level of cost sharing often vary by the type of plan in which the beneficiary is enrolled. Cost sharing may also vary by the type of service, such as office visits, hospitalizations, or prescription drugs.
Under Medicare FFS Part A, the inpatient deductible (the amount the patient must pay prior to insurance coverage of inpatient services) is $1,676 in Fiscal Year 2026.1 Days 1-60 of an inpatient stay have a $0 copayment and 0% coinsurance for each benefit period. Medicare FFS Part B comes with a deductible of $257 in 2026.1 Once the patient pays $257, Medicare pays 80% of the Medicare-approved amount, and the patient is responsible for 20% of the approved amount. This 20% coinsurance amount is applied to costs other than the CAR T cell therapy acquisition cost. The hospital outpatient department (HOPD) copayment for CAR T cell therapies is capped at the inpatient deductible.2
This tool assumes Medicare patients are covered by traditional Medicare, in which no limit on out-of-pocket costs for Part A and Part B exist. Note that Medicare supplemental insurance, or Medigap plans, can help reduce the burden of out-of-pocket costs for original Medicare.
For privately covered patients, the annual deductible is assumed to be $3,057 in 2024.3 The coinsurance rate for inpatient and outpatient procedures and visits is assumed to be 20%.4 The same coinsurance rate applies to drugs (specialty and non-specialty). Privately covered patients are assumed to have an out-of-pocket maximum of $9,200 in both settings of care in 2025.5
