This act caps Medicare beneficiary coinsurance for certain outpatient surgery center services at the annual inpatient hospital deductible amount.
Bill Cassidy
Senator
LA
The Medicare Beneficiary Co-Pay Fairness Act limits the coinsurance amount Medicare beneficiaries must pay for certain outpatient surgery center services. If the standard coinsurance exceeds the annual inpatient hospital deductible, this bill caps the beneficiary's out-of-pocket cost at that deductible amount. This change aims to reduce unexpected out-of-pocket expenses for patients receiving outpatient care.
Medicare Bill Caps Outpatient Surgery Co-Pays at Inpatient Deductible Rate Starting 2026
The newly named Medicare Beneficiary Co-Pay Fairness Act is pretty straightforward: it’s designed to put a hard ceiling on how much Medicare beneficiaries have to pay out-of-pocket for certain facility services when they have surgery at an Ambulatory Surgical Center (ASC).
The 'What' and the 'When'
Right now, if you’re on Medicare and need an outpatient procedure at an ASC, you pay a coinsurance amount. This bill (SEC. 2) says that if that coinsurance calculation ends up being more than the annual Medicare inpatient hospital deductible—the amount you’d pay before inpatient coverage kicks in—the government steps in to cap your payment. Essentially, your out-of-pocket cost for that facility fee can never exceed that year’s inpatient deductible. The government will then pick up the rest of the tab, paying the difference directly to the ASC. This change is scheduled to take effect for services provided on or after January 1, 2026.
Capping the Surprise Bill
Think of this as a financial safety net for outpatient surgery. For example, if the standard coinsurance for a complex procedure at an ASC is calculated at $2,000, but the annual inpatient deductible for that year is set at $1,600, you, the beneficiary, would only have to pay $1,600. Medicare would pay the remaining $400 directly to the ASC. This is a big deal for financial predictability. When you’re facing surgery, the last thing you need is a massive, unexpected coinsurance bill that exceeds what you’d pay for a full hospital stay. This provision gives beneficiaries a clear, known maximum cost for that part of the bill.
Who Pays the Difference?
While this is clearly a win for the Medicare beneficiary—it reduces their potential financial burden and increases cost certainty—it doesn't mean the cost disappears. The financial responsibility is simply shifting. Instead of the patient paying the excess, the Medicare program (and ultimately, the taxpayer funding the program) covers the difference. For ASCs, this is beneficial because they are guaranteed payment up to that deductible level, ensuring they get compensated even when the patient’s liability is capped. This is a classic trade-off in healthcare policy: reducing the cost burden on the individual often means increasing the payout from the public payer.