Maine became the latest state to exempt most ASCs from certificate-of-need review in 2026, one of nine states that changed CON rules this year. Tennessee will stop requiring CON for new ASCs Dec. 1, 2027.
The federal government is adding pressure. The $50 billion Rural Health Transformation Program rewards states that repeal or loosen CON, though the factor counts for just 1.75% of a state’s score, according to the Bipartisan Policy Center.
Changes affecting ASCs
- Maine: LD 1890 exempts most ASCs from CON review and raises the capital spending threshold to $7.5 million from $3 million, according to HFMA. It became law without the governor’s signature March 31.
- Connecticut: Public Act 26-68 overhauls the state’s CON program. The law took effect Oct. 1, but most CON changes start July 1, 2027. It defines a change of ownership as an acquisition of 25% or more of a facility’s assets, equity or voting shares. After June 30, 2027, outpatient surgical facilities can end surgical services without a CON. Relocations within the same town or within 10 miles are exempt if payer mix and patient population don’t substantially change. An expedited review for adding two or three operating rooms within three years must be in place by Jan. 1, 2028, according to Pullman & Comley.
- Iowa: HF 2635, signed in May, drops letters of intent and public hearings as of July 1. It raises the review threshold to $4 million in 2027, $4.5 million in 2032 and $5 million in 2037, according to Iowa HHS. New ASCs still need CON review, according to AAOS.
Other 2026 CON changes
- Tennessee: SB 1369 ends CON for freestanding emergency departments and cardiac catheterization by 2028 and for most acute care hospitals in 2030, according to HFMA.
- North Carolina: The state budget, signed by Gov. Josh Stein in July, repealed CON for inpatient rehab, effective Oct. 1, according to Carolina Journal.
- Delaware: HB 17, signed May 12, repealed CON review for major medical equipment purchases, effective July 1. Capital projects above $5.8 million still need review, according to Spotlight Delaware.
- Mississippi: HB 3 doubled the spending thresholds that trigger review, including raising the clinical improvement trigger to $10 million from $5 million, according to Mississippi Today. It took effect when signed Feb. 4. A second law, HB 1622, exempts existing hospitals in small communities from CON for capital projects, according to Bradley.
- Nebraska: LB 437 extends CON approvals to three years from one.
- Virginia: HB 1337, signed April 13, creates expedited CON review for certain projects, according to HFMA.
Phase-outs coming due
- Tennessee: ASCs licensed on or after Dec. 1, 2027, will not need CON, under a 2024 law. Those centers must take TennCare and provide comparable charity care, according to Bass Berry.
- South Carolina: ASCs are already out of CON. Hospital CON ends Jan. 1, 2027.
- North Carolina: ASCs in counties of more than 125,000 people have been exempt since Nov. 1, 2023. Draft state data from 2026 license renewals lists 90 such centers in 16 counties, 25 of them in Wake County, according to NC DHHS.
Fights that stalled
- North Carolina: S 1040 would repeal CON for ASCs and inpatient rehab. It cleared the Senate Health Committee in May and has not passed.
- Virginia: HB 1201, a certificate of public need exception for independent ASCs with up to three operating rooms, was tabled 6-2 by a House subcommittee Feb. 10.
- Kentucky: HB 407 would have limited CON hearings and appeals to applicants and required decisions within 90 days. It stalled in April. SB 348, which would have exempted some ophthalmology and endoscopy centers, never left committee.
- Hawaii: The Senate Health and Human Services Committee stripped an ASC exemption from SB 2289.
- West Virginia: Gov. Patrick Morrisey is still pushing repeal. Marshall Health Network and two Republican lawmakers defended the law Oct. 20.
CON in practice
CON still shapes ASC strategy where it stands. In Illinois, CON kept NueHealth from building new. Kendall Pointe Surgery Center in Oswego, which NueHealth has managed since 2020, instead spent more than $3.5 million to add a fourth OR inside its existing building. In Tennessee, regulators voted 7-1 Sept. 23 to deny an $11.8 million cardiovascular ASC in Cookeville.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
