Sponsors (5)
The bill caps beneficiary coinsurance and shifts certain office procedures into a facility-payment model to provide predictable rules and protect provider revenue, but it may raise some beneficiaries' out-of-pocket costs, increase Medicare spending, and impose new administrative burdens and uncertainty for small practices.
Medicare beneficiaries who get certain high-supply surgical procedures in qualifying physician offices will have their coinsurance capped so they never pay more than the annual inpatient hospital deductible for that year.
Office-based facilities and small provider practices performing covered procedures will receive facility-style payments (pegged to 90% of ASC facility rates) and the Secretary must raise facility payments when the coinsurance cap would otherwise reduce provider revenue, protecting provider income for these services.
Patients and providers will benefit from a predictable, annually reviewed list and supply-price threshold of qualifying high-supply procedures (starting 2027) so stakeholders can anticipate which services qualify for the coinsurance cap and facility payments.
Some Medicare beneficiaries could end up paying more out-of-pocket for these procedures than under current physician-office non-facility billing because facility coinsurance still applies (it is capped but not eliminated).
Shifting many procedures into a facility-payment framework and increasing facility-level payments may raise overall Medicare spending, increasing costs to 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 that could strain or deter small practices.
Based on analysis of 2 sections of legislative text.
Creates Medicare payment rules to pay qualifying office-based physician offices for certain high-supply-cost surgical procedures at rates tied to ASC payments starting in 2027.
Official title: To amend title XVIII of the Social Security Act to align payment under Medicare for specified surgical procedures with high-cost supplies furnished in office-based facilities, and for other purposes.
Introduced March 9, 2026 by Gus Bilirakis · Last progress March 9, 2026
Creates a new Medicare payment category for certain high-supply-cost surgical procedures performed in qualifying office-based physician offices and pays those offices similarly to ambulatory surgical centers (ASCs) beginning in 2027. It defines “specified high supply cost surgical procedures” with an initial supply-cost threshold (based on 2023 inputs) and sets facility payments for eligible office-based facilities at generally 90% of the ASC facility rate, with rules to prevent beneficiaries’ coinsurance from exceeding the inpatient hospital deductible. The bill requires office-based facilities to meet Secretary standards, enroll and agree to payment and assignment terms, and triggers rulemaking and annual review processes for the list of covered procedures starting in 2028. It also makes conforming changes to ASC and off-campus outpatient payment rules and adds office-based facilities into Medicare enrollment and conditions-of-participation consultations.