An article in Radiology Business reports the re-introduction of the Medicare Access to Radiology Care Act of 2026 (MARCA) by U.S. Senators John Boozman (R-Arkansas) and Ben Ray Lujan (D-New Mexico). The proposed legislation would amend Medicare Part B to create an express statutory payment pathway for certain radiologist assistant (RA) services. The central concept is that Medicare would recognize a new category of covered service: “radiologist assistant services” furnished by an ARRT-certified radiologist assistant, under the supervision of a radiologist, when the service is within the RA’s state-law scope of practice and when no other provider, other than the supervising radiologist, bills or is paid for that same service.

The new draft makes a major technical improvement to prior versions of MARCA introduced in previous sessions of Congress. The payment provisions no longer applies “incident to” billing rules to the payment to the radiologist who supervises the RA, a significant modification, since the “incident to” Medicare billing rules are inconsistent with the relationship most radiologists have with their patients and the typical performance of radiology services.

Unfortunately, however, the legislation does not appear to provide coverage for RA services performed in physician offices, which are not expressly included in the definition of “covered facility setting.” In the draft legislation, the defined covered facility settings are hospitals, critical access hospitals (CAHs), ambulatory surgical centers (ASCs), and other “providers of services” the Secretary may specify.  A physician's office or independent diagnostic testing facility is not naturally included in that definition unless CMS later treats a particular setting as covered through rulemaking or another statutory mechanism.

The failure to include physician offices appears to arise from a misunderstanding of the current state of Medicare regulation of RA services. Senator Boozman’s press release indicates that, “In 2019, the Centers for Medicare & Medicaid Services adjusted RA supervision requirements, which allowed providers to be reimbursed by Medicare for services performed by RAs in the office setting.” This is a misstatement.  Revisions to 42 CFR 410.32(b) in the 2019 Medicare Physician Fee Schedule final rule permit Level 3 fluoroscopic-guided tests performed by licensed RAs and radiology practitioner assistants (RPAs) to be supersized under direct and not personal supervision.  In other words, if a barium enema is performed by a state-licensed or authorized RA, the radiologist need not perform “in the room” personal supervision. That Medicare rule change permits “direct” supervision, meaning that the supervising physician need not be in the procedure room throughout the performance of a test such as the barium study.  

It is unlikely that the proponents of this legislation intend for RA services in office settings to be limited to Level 3 tests that can be performed under direct, rather than personal, supervision. They would certainly want to work with RAs in a physician's office setting for more than just diagnostic tests, but also to have the ability to supervise RAs who are qualified to perform various minimally invasive procedures that are appropriate in office settings.

My reading is that this bill would permit payment to the supervising radiologist for covered RA services furnished only in hospitals, CAHs, and ASCs, assuming the RA is ARRT-certified, the service is within state scope of practice, the radiologist supervises the service, and no other provider is paid for the same furnishing of the service.

For physician offices, this new draft leaves existing office-based Medicare payment rules undisturbed. This new statutory payment language is not drafted as an unrestricted “all settings” rule. Because the patrons believe no change is needed for office-based services, the bill would be clearer if “physician offices,” “independent diagnostic testing facilities,” or “nonfacility settings” were expressly included, or if the payment provision were not limited to “covered facility settings.”

This new draft is a vast improvement over prior versions due to the removal of “incident to” billing requirements. But for this legislation to work as the proponents desire, I hope that it will be revised to include office-based services.