Sponsors (5)
The bill caps beneficiary coinsurance for certain high-supply office procedures and raises facility payments to protect providers, trading off the potential for higher out-of-pocket costs for some beneficiaries and increased Medicare spending and administrative burden.
Medicare beneficiaries who get qualifying high-supply surgical procedures in certain physician offices will have their coinsurance capped so they never pay more than the inpatient hospital deductible for that year.
Office-based facilities and small physician practices performing specified procedures will get facility payments set at 90% of ambulatory surgical center (ASC) rates and guaranteed adjustments when caps would reduce payment, helping protect provider revenue.
Providers and patients will benefit from a predictable, annually reviewed list and threshold for which procedures qualify for the policy starting in 2027, improving planning and transparency.
Some Medicare beneficiaries could face higher out-of-pocket costs for these procedures than under current non-facility physician-office billing because facility coinsurance still applies (albeit capped).
Shifting procedures into a facility-payment framework may increase overall Medicare spending for these services compared with current physician-office non-facility payments, potentially raising costs for taxpayers and the program.
Small physician offices must meet new Secretary standards, enter agreements, and accept assignment to qualify, creating additional administrative burden and compliance costs for practices.
Based on analysis of 2 sections of legislative text.
Creates Medicare payment rules to pay qualifying office-based physician offices for high-supply-cost surgical procedures at 90% of the ASC facility rate and caps beneficiary coinsurance at the inpatient deductible (effective 2027).
Introduced March 9, 2026 by Gus Bilirakis · Last progress March 9, 2026
Creates a new Medicare payment category for certain surgical procedures that have high supply costs when performed in qualifying office-based physician offices and pays those office-based facilities a facility rate similar to ambulatory surgical centers (ASCs) beginning in 2027. It sets a supply-cost threshold (based on 2023 supply prices, initially greater than $500 and indexed thereafter), requires facilities to meet Medicare standards and enroll, and directs annual Secretary reviews and rulemaking starting in 2028. Payment generally equals 90% of the ASC facility payment with a patient coinsurance cap no greater than the inpatient hospital deductible; if coinsurance would otherwise exceed that deductible, the Secretary must raise the facility payment so the provider is made whole. The change also updates related ASC and off-campus outpatient payment rules and adds office-based facilities into Medicare enrollment/agreement and consultation processes with State agencies for conditions of participation.