This bill limits the Medicare coinsurance amount for certain ambulatory surgical center services to the annual inpatient hospital deductible, effective January 1, 2026.
Mike Kelly
Representative
PA-16
This bill amends Medicare rules to cap the out-of-pocket coinsurance amount beneficiaries must pay for certain services provided in an Ambulatory Surgical Center (ASC). If the standard ASC coinsurance exceeds the annual inpatient hospital deductible, the beneficiary's cost will be limited to that deductible amount. The Secretary will cover the difference owed to the ASC.
Medicare Bill Caps Outpatient Surgery Coinsurance Starting 2026, Limiting Patient Costs
If you’re on Medicare, you know that even with coverage, a major procedure can still hit your wallet hard. Right now, when you get facility services at an Ambulatory Surgical Center (ASC)—think same-day, outpatient surgery—you pay a coinsurance amount that can sometimes feel like a massive bill.
This new legislation (Section 1) aims to put a firm ceiling on that out-of-pocket cost, starting January 1, 2026. The rule is simple: if the coinsurance amount Medicare requires you to pay for that ASC procedure is higher than the standard Medicare inpatient hospital deductible for that year, your payment gets capped at that deductible amount. Essentially, the most you’d pay for that facility fee is the equivalent of the standard deductible.
The Cap: Fixing the Outpatient Price Tag
This change is all about bringing predictability and relief to Medicare beneficiaries who need outpatient surgery. For example, let’s say the standard inpatient deductible is $1,600 in 2026. If your coinsurance for an ASC procedure was calculated at $2,500, this bill says you only have to pay the $1,600 deductible amount. That’s an immediate $900 saving for the patient right there.
Why does this matter? ASCs are often cheaper than full hospitals, but unpredictable coinsurance costs can still create a significant financial barrier, especially for those on fixed incomes. By setting the inpatient deductible as the maximum coinsurance, the bill ensures that a patient’s financial exposure for an outpatient procedure won't exceed what they would pay for the deductible of a much more expensive inpatient hospital stay.
Who Picks Up the Rest of the Tab?
This legislation doesn't leave the ASCs hanging. The bill specifically mandates that the Secretary of Health and Human Services must pay the difference to the surgical center. In the example above, Medicare would pay the ASC the remaining $900 that the patient no longer has to cover.
This shifts the cost burden from the individual Medicare patient directly onto the Medicare program itself. For the patient, this is a clear win: lower, more predictable out-of-pocket spending. For the federal government, this means an increase in Medicare expenditures to cover the newly capped amounts. For ASCs, this provides certainty that they will still receive their full negotiated payment, mitigating any potential financial risk from the coinsurance cap, though it does add a layer of administrative complexity to their billing process.