HR-3006-119
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Sponsored by Mike Kelly (R-PA)
What it does
This bill would amend Medicare law to cap the coinsurance amount a patient pays for facility services at an ambulatory surgical center for a surgical procedure, so it cannot exceed the annual inpatient hospital deductible. When the standard coinsurance calculation would produce a higher amount, Medicare would pay the surgical center the difference to make up for the reduced patient payment. The change would apply to services furnished on or after January 1, 2026.
Who benefits
Medicare beneficiaries who undergo surgical procedures at ambulatory surgical centers, particularly those facing high coinsurance bills for costly procedures; ambulatory surgical centers, which would receive an offsetting payment from Medicare instead of collecting higher amounts from patients (and would avoid the collections burden and bad debt risk of chasing large patient balances); patient advocacy groups focused on reducing out-of-pocket costs.
Who is hurt
The Medicare Trust Fund and federal budget bear the cost of the offsetting payments to surgical centers, which could add to program spending over time. Taxpayers and, indirectly, future Medicare beneficiaries could be affected if increased spending contributes to solvency pressures on the Hospital Insurance or Supplementary Medical Insurance trust funds. Hospitals that also perform outpatient surgery but are not classified as ambulatory surgical centers would not receive the same coinsurance cap, potentially creating a competitive disadvantage for them.
Supporters argue
Supporters argue that current Medicare coinsurance rules can expose patients to surprisingly high out-of-pocket costs for surgical procedures performed at ambulatory surgical centers, sometimes exceeding what they would pay for the same procedure in a hospital setting. They contend capping coinsurance at the inpatient hospital deductible level protects patients from disproportionate cost-sharing while preserving the lower overall cost of outpatient surgical centers compared to hospitals, encouraging use of a less expensive care setting.
Opponents argue
Opponents argue that reimbursing surgical centers for the coinsurance reduction shifts costs from patients onto the Medicare program without a corresponding funding offset, adding to federal spending at a time of concern over Medicare's long-term solvency. They contend the bill creates an uneven playing field by favoring one care setting over hospital outpatient departments performing similar procedures, and that a narrower fix targeting only the highest-cost procedures might achieve the same patient protection at lower cost.
Constitutional context
This bill exercises Congress's spending power under the Taxing and Spending Clause (Article I, Section 8, Clause 1) to modify Medicare payment and cost-sharing rules, a routine exercise of authority over a federal spending program rather than a novel constitutional question.
Checks and balances
Congress sets the coinsurance formula in statute; the Secretary of Health and Human Services implements it through Medicare regulations and payment systems, with agency rules subject to judicial review.
Historical precedent
Congress has periodically adjusted Medicare cost-sharing formulas for specific service settings, including past changes affecting ambulatory surgical center payment rates and hospital outpatient coinsurance caps under the Balanced Budget Act of 1997.