While CMS’ addition of more 573 codes to the ASC Covered Procedures list has been cause for celebration for many leaders, a Medicare policy affecting coinsurance payments for certain procedures may be disincentivizing patients from using ASCs and creating barriers to lower-cost care settings.
For many procedures, Medicare beneficiaries are responsible for paying 20% of the procedure costs — but this responsibility is capped in the hospital setting. The cap for 2026 is $1,736 — but unlike ASCs, hospitals are “made whole” by the Medicare program after the patient cap is met, Kara Newbury, chief advocacy officer for the Ambulatory Surgery Center Association, told Bekcer’s.
“I call it a double whammy,” Ms. Newbury said. “Because not only is the policy incentivizing procedures to go to the higher cost setting, but then they’re also being made whole, so the portion they would have gotten from the beneficiary, they get from the Medicare program.”
ASCs are likely to see this policy affect higher-cost procedures, particularly in cardiology, orthopedics and those involving devices or implants, she added. For example, according to CMS’ procedure price lookup tool, a total knee replacement costs $10,552 in the ASC, compared with $14,275 in the HOPD.
Despite the lower overall cost, patients pay $142 more in ASCs due to the lack of a coinsurance cap.
“Surgeons weren’t aware of this issue — so some patients were coming to them and saying, ‘Hey, I’m going to have to pay more.’ And so then the surgeon decides to take them to the hospital,” Ms. Newbury said. She added that this scenario has specifically played out in pacemaker insertion cases.
The policy may have other negative consequences for patient access and health equity. The issue primarily affects those without supplemental insurance coverage, which, according to ASCA, is “an area where a racial disparity in access has been observed, with only 40% of Black beneficiaries being covered by supplemental insurance in contrast to 72% of white beneficiaries.”
This is part of ASCA’s current advocacy platform on this issue, which includes their push for the passage of the Medicare Beneficiary Co-Pay Fairness Act. ASCA said on its website that by enacting this legislation “Congress would ensure Medicare beneficiaries are not penalized for choosing the high-quality, lower-cost site of service that ASCs provide.” It would do so by creating a coinsurance cap for ASCs similar to the HOPD cap and making the facility whole for the difference in pay.
Ms. Newbury said that this proposal has bipartisan sponsorship in both chambers of Congress, but requires a statutory update rather than a regulatory adjustment. ASCA estimates that if this policy were implemented, a 6% market share shift to ASCs for impacted procedures would result in a budget-neutral effect on federal spending, and any further procedure migration would actually create savings for Medicare.
However, given the current pressure on Congress amid ongoing geopolitical conflicts in Iran, Ms. Newbury is “not overly optimistic” about the swift passage of healthcare policy in the near future.
