To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center.
- Sponsor
- Rep. Kelly, Mike [R-PA-16]
- Committees
- Ways and Means Committee (primary)
- Last action
- Apr 24, 2025
Bottom line
This bill caps Medicare beneficiary coinsurance for ambulatory surgical center facility services at the inpatient hospital deductible, reducing out-of-pocket costs for certain surgical procedures and shifting costs to the Medicare program.
What it actually does
This bill amends the Social Security Act to cap the coinsurance amount that Medicare beneficiaries pay for facility services received in an ambulatory surgical center (ASC) for surgical procedures. Specifically, if the coinsurance for such services would exceed the annual inpatient hospital deductible, the bill mandates that the coinsurance be reduced to match that deductible amount, with Medicare covering the difference. This aims to reduce out-of-pocket costs for beneficiaries undergoing surgery in ASCs, effective January 1, 2026.
Proponents argue
Supporters argue this bill will make surgical procedures performed in ambulatory surgical centers more affordable and financially predictable for Medicare beneficiaries by preventing unexpectedly high coinsurance costs. They contend that capping these out-of-pocket expenses at a familiar deductible level will encourage beneficiaries to utilize cost-effective ASCs, which are often less expensive than hospital outpatient departments for similar procedures. This could lead to better access to necessary care and reduce financial burdens on seniors.
Opponents contend
Opponents might argue that while the bill aims to reduce beneficiary costs, it shifts the financial burden to the Medicare program, potentially increasing federal expenditures without addressing the underlying costs of healthcare services. They might also raise concerns about the potential for unintended consequences, such as encouraging overutilization of ASC services if the cost-sharing is significantly reduced, or creating an imbalance in cost-sharing structures between different types of healthcare settings.
The bill is very short and clearly written, making it highly accessible for a reader to understand its core provisions quickly.
Section 1(a)(1) and (2), amending Section 1833 of the Social Security Act
Limitation on Coinsurance for Ambulatory Surgical Center Services
This provision amends Medicare law to ensure that the coinsurance amount a beneficiary pays for facility services at an ambulatory surgical center (ASC) for a surgical procedure cannot exceed the inpatient hospital deductible for that year. If the calculated coinsurance would be higher than the deductible, it is reduced to the deductible amount, and Medicare pays the ASC the difference. This change takes effect for services furnished on or after January 1, 2026.
Supporters argue
Supporters argue this cap will protect Medicare beneficiaries from unexpectedly high out-of-pocket costs when choosing ASCs, which are often more efficient and lower-cost settings than hospitals for many procedures. This financial predictability can improve access to care and encourage the use of appropriate, lower-cost settings.
Critics contend
Critics might contend that while beneficial for beneficiaries, this provision shifts costs directly to the Medicare program, increasing federal spending without addressing the underlying cost structure of ASC services. It could also create an incentive for beneficiaries to choose ASCs over other settings even when the cost difference isn't substantial, leading to higher overall Medicare outlays.
Tradeoffs
The bill balances the goal of reducing financial burden on Medicare beneficiaries and potentially encouraging the use of more cost-effective ASCs against the increased direct cost to the Medicare program. It aims to provide cost predictability for patients but transfers the financial variability to the federal budget.