Medicare Beneficiary Co-Pay Fairness Act
- Sponsor
- Sen. Cassidy, Bill [R-LA]
- Committees
- Finance Committee (primary)
- Last action
- May 15, 2025
Bottom line
This bill aims to reduce out-of-pocket costs for Medicare beneficiaries undergoing surgical procedures in ambulatory surgical centers by capping their coinsurance payments at the inpatient hospital deductible level.
What it actually does
This bill amends the Social Security Act to cap the out-of-pocket coinsurance amount that Medicare beneficiaries pay for facility services at ambulatory surgical centers (ASCs) for surgical procedures. If the standard coinsurance would exceed the Medicare Part A inpatient hospital deductible, the bill reduces the beneficiary's payment to that deductible amount and directs the Secretary of Health and Human Services to pay the difference to the ASC. The amendments apply to services furnished on or after January 1, 2026.
Proponents argue
Proponents argue this bill protects Medicare beneficiaries from unexpectedly high out-of-pocket costs for surgical procedures performed in ASCs, aligning their financial responsibility more closely with costs for inpatient hospital services and promoting access to cost-effective outpatient care settings. They emphasize that it addresses a potential financial barrier for seniors needing surgery, especially as more procedures shift to outpatient settings, ensuring financial predictability.
Opponents contend
Opponents might argue that capping coinsurance could increase federal spending by shifting costs from beneficiaries to the Medicare program, potentially exacerbating long-term solvency concerns. They might also contend that it could create an unintended incentive for ASCs to perform more procedures that approach the cap, or that it distorts the cost-sharing structure designed to encourage judicious use of services, leading to higher overall program costs.
The bill is very short and easily digestible, allowing ample time for informed evaluation.
Section 2(a), amending Section 1833 of the Social Security Act
Limitation on Coinsurance for Ambulatory Surgical Center Facility Services
This provision amends the Social Security Act to ensure that Medicare beneficiaries' coinsurance payments for facility services received at an ambulatory surgical center (ASC) for a surgical procedure do not exceed the annual inpatient hospital deductible under Medicare Part A. If the calculated coinsurance would be higher than this deductible, it is reduced to the deductible amount, and Medicare pays the difference to the ASC, effective for services furnished on or after January 1, 2026.
Supporters argue
Supporters argue this cap protects vulnerable seniors from potentially burdensome out-of-pocket costs for necessary surgeries, making ASCs a more financially predictable and accessible option. They contend it promotes equity by aligning ASC cost-sharing with inpatient hospital deductibles, which are often perceived as a more familiar and manageable out-of-pocket expense for beneficiaries.
Critics contend
Critics might argue that this provision shifts costs from beneficiaries to the federal government, increasing Medicare's financial obligations without necessarily addressing underlying healthcare costs. They might also suggest it could lead to higher utilization of certain ASC services if beneficiaries perceive lower personal cost, potentially driving up overall program spending.
Tradeoffs
The provision balances the goal of reducing beneficiary out-of-pocket costs and promoting access to ASCs against the potential for increased federal Medicare expenditures and the implications for the program's long-term financial sustainability. It also navigates the tension between patient affordability and the principles of cost-sharing designed to influence healthcare consumption.