To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center. (HR-3006)

Bill Summary

Summary

Limits how much Medicare beneficiaries pay in coinsurance for facility fees when a surgical procedure is performed in an ambulatory surgical center (ASC) by capping that coinsurance at the annual inpatient hospital deductible for the applicable year. If the usual coinsurance would be higher than that deductible, Medicare must reduce the beneficiary’s coinsurance to the deductible amount and pay the ASC supplier the difference. The change applies to services furnished on or after January 1, 2026.

Key Points

Caps Medicare coinsurance for ASC facility services at the annual inpatient hospital deductible.
If normal coinsurance would exceed the deductible, beneficiary liability is reduced to the deductible amount.
Medicare must pay the ASC supplier an amount equal to the reduction so suppliers are made whole.
Applies to services furnished on or after January 1, 2026.
Requires CMS to update claims processing and payment calculations for ASCs.
Reduces out-of-pocket costs for Medicare beneficiaries receiving ASC facility services.
Likely increases Medicare program payments because Medicare covers the reduction amount.

Pros & Cons

The bill reduces and stabilizes out-of-pocket costs for Medicare patients using ASCs and protects ASC payments, at the expense of higher Medicare spending that may prompt cost-shifting by payers or modest increases in utilization.

Potential Benefits

3

Medicare beneficiaries (seniors and other Medicare enrollees) will pay lower out-of-pocket coinsurance for ambulatory surgical center (ASC) facility services and face more predictable procedure costs starting Jan 1, 2026.
Ambulatory surgical center (ASC) suppliers will receive payments covering the difference between higher coinsurance and the inpatient deductible, protecting ASC revenue and preventing payment shortfalls for providers.
Capping patient coinsurance exposure for ASC services increases billing predictability, helping Medicare enrollees and their households better budget for planned procedures.

Potential Drawbacks

3

Taxpayers and the Medicare program will face higher federal spending because Medicare must pay the coinsurance difference to ASC suppliers, increasing program outlays.
Insurers, Medicare contractors, or providers may adjust ASC payment policies, provider rates, or contracting to offset added program costs, which could shift costs elsewhere or affect provider networks and patient access.
Lower out-of-pocket costs could increase utilization of ASC services, modestly raising overall Medicare use and program spending and potentially placing additional strain on program budgets.

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Categories & Tags

Agencies

HHS

Centers for Medicare & Medicaid Services

Subjects

Medicare

Health Insurance Coverage

Healthcare Workforce

Affected Groups

Medicare Beneficiaries

Seniors & Retirees

Hospitals & Health Systems

Healthcare Workers

To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center.

Bill Summary

Summary

Key Points

Pros & Cons

Potential Benefits

Potential Drawbacks

AI Insights

Categories & Tags

Sponsors (22)

Sponsors (22)

Bill Summary

Summary

Key Points

Pros & Cons

Potential Benefits

Potential Drawbacks

AI Insights

Categories & Tags

To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center.