To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center.
Summary
What This Bill Does
This bill amends Medicare payment rules in section 1833 of the Social Security Act. For ambulatory surgical center facility services, if the normal coinsurance calculation would make the beneficiary owe more than the inpatient hospital deductible for that year, the Secretary must reduce the coinsurance to the inpatient deductible amount and pay the ambulatory surgical center supplier the amount of the reduction. The rule applies to services furnished on or after January 1, 2026. The bill therefore caps beneficiary exposure for high-cost ASC procedures while keeping the supplier whole through an additional Medicare payment.
Who Benefits and How
Medicare beneficiaries using ambulatory surgical centers benefit because coinsurance for covered facility services cannot exceed the inpatient hospital deductible. Patients needing higher-cost outpatient surgical procedures benefit from reduced out-of-pocket exposure beginning in 2026. Ambulatory surgical centers benefit because Medicare pays the supplier the amount by which beneficiary coinsurance is reduced. Patient advocates benefit from a clear statutory cap tied to the familiar inpatient hospital deductible.
Who Bears the Burden and How
CMS must update ASC payment systems to compare coinsurance against the inpatient deductible and calculate supplier payments. Federal Medicare spending increases when Medicare pays reductions that beneficiaries otherwise would have owed. Ambulatory surgical center billing staff must implement the cap for services furnished on or after January 1, 2026. Medicare fiscal intermediaries must process additional supplier payments tied to coinsurance reductions.
Key Provisions
- Amends section 1833 to cap certain ASC facility-service coinsurance at the inpatient hospital deductible.
- Requires the Secretary to reduce beneficiary coinsurance when it would exceed the deductible cap.
- Requires Medicare to pay the ASC supplier the amount of the coinsurance reduction.
- Applies the new rule to services furnished on or after January 1, 2026.
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers with clause-level evidence links.
At a Glance
What This Bill Does
Caps Medicare beneficiary coinsurance for certain ambulatory surgical center facility services at the inpatient hospital deductible amount beginning January 1, 2026, with Medicare paying suppliers the reduction.
Key Policy Areas
Medicare, Ambulatory Surgery, Patient Costs
Primary Purpose
Caps Medicare beneficiary coinsurance for certain ambulatory surgical center facility services at the inpatient hospital deductible amount beginning January 1, 2026, with Medicare paying suppliers the reduction.
Policy Domains
Resolution provisions
Identified Gains
- Medicare beneficiaries using ambulatory surgical centers
- Patients needing outpatient surgical procedures
- Ambulatory surgical centers
- Patient advocates
Identified Costs
- CMS
- Federal Medicare program
- Ambulatory surgical center billing staff
- Medicare fiscal intermediaries
Sponsors
Legislative Progress
In CommitteeMr. Kelly of Pennsylvania (for himself, Mr. Menendez, Mr. Balderson, …
Referred to the Committee on Energy and Commerce, and in …
Introduced in House
Stakeholder Effects
cui bono?How this legislation distributes effects. Mention counts reflect frequency, not effect magnitude.
Federal Medicare program, Medicare beneficiaries using ambulatory surgical centers
Positive-direction: Medicare beneficiaries using ambulatory surgical centers
Negative-direction: Federal Medicare program
Ambulatory surgical centers, Patients needing outpatient surgical procedures
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology