To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center.
- Bill Number
- H.R. 3006
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-04-24: 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.
- Last Updated
- 2026-02-10T09:05:53Z
AI-Generated Summary
Purpose
The bill, H.R. 3006, aims to reduce out-of-pocket costs for Medicare beneficiaries receiving certain surgical services in ambulatory surgical centers (ASCs). ASCs are outpatient facilities where surgeries are performed without an overnight hospital stay. By capping the patient's coinsurance (a share of the cost they must pay after insurance covers its portion), the legislation seeks to make these procedures more affordable, potentially encouraging their use over more expensive inpatient hospital options.
Key Provisions
- Amendment to Medicare Payment Rules: The bill modifies Section 1833 of the Social Security Act, which governs Medicare Part B payments for outpatient services.
- It updates the existing rule on coinsurance for ASC facility services to include a new limitation.
- Adds a new subsection (ee) that applies specifically to facility services (like operating room fees) for surgical procedures in ASCs.
- Coinsurance Cap: If the standard 20% coinsurance amount would exceed the annual inpatient hospital deductible (a fixed amount set each year, currently around $1,600, that patients pay before Medicare covers hospital stays), the patient's coinsurance is reduced to match that deductible.
- Medicare Payment Adjustment: The Centers for Medicare & Medicaid Services (CMS) must pay the ASC provider the difference between the original coinsurance amount and the capped amount.
- Effective Date: Changes apply to services provided on or after January 1, 2026.
Significant Changes to Existing Law
- Under current law, Medicare Part B requires beneficiaries to pay 20% coinsurance for ASC facility services with no upper limit, which can sometimes exceed the inpatient hospital deductible.
- This bill introduces the first statutory cap on ASC coinsurance, tying it directly to the inpatient deductible under Section 1813(b) of the Social Security Act. This shifts excess costs from patients to Medicare, without altering the overall payment rates to providers.
Potential Impacts
- On Citizens: Medicare beneficiaries, particularly older adults or those with disabilities undergoing outpatient surgeries, will face lower maximum out-of-pocket costs for ASC procedures, potentially improving access to care and reducing financial burdens.
- On Government Agencies: CMS and the Medicare program will incur higher expenditures, as it covers the reduced coinsurance amounts paid to ASCs. This could increase federal spending on Medicare Part B by an undetermined amount, possibly requiring budget adjustments.
- On International Relations: No direct impacts, as the bill focuses solely on domestic U.S. healthcare policy.
- Broader Effects: May promote a shift toward cost-effective outpatient surgeries, potentially lowering overall healthcare costs if fewer inpatient procedures are needed, though short-term Medicare costs could rise.
Main Stakeholders Affected
- Medicare Beneficiaries: Primary beneficiaries who receive surgical services in ASCs and will pay less in coinsurance.
- Ambulatory Surgical Centers and Providers: ASCs and surgeons will receive full payment from Medicare for the capped amounts, ensuring stable revenue without relying on higher patient contributions.
- Centers for Medicare & Medicaid Services (CMS): Responsible for implementing the changes, adjusting payments, and managing increased program costs.
- Taxpayers and Congress: Indirectly affected through higher federal Medicare spending, which may influence future budgeting and healthcare policy debates.
Notable Legal, Constitutional, or Political Implications
- Legal: The bill makes a targeted fiscal adjustment to Medicare without altering broader payment structures, likely facing minimal legal challenges as it aligns with Congress's authority over entitlement programs. It requires CMS rulemaking to implement the payment process.
- Constitutional: No apparent issues; it involves spending under the Spending Clause and does not infringe on individual rights.
- Political: Could appeal to bipartisan support for protecting seniors from high healthcare costs, as evidenced by cosponsors from both parties. However, it may spark debates over Medicare's solvency amid rising costs, potentially influencing future healthcare reform efforts.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (21)
Rep. Menendez, Robert [D-NJ-8], Rep. Balderson, Troy [R-OH-12], Rep. Larson, John B. [D-CT-1], Rep. Bost, Mike [R-IL-12], Rep. Mann, Tracey [R-KS-1], Rep. Ross, Deborah K. [D-NC-2], Rep. Gottheimer, Josh [D-NJ-5], Rep. Lieu, Ted [D-CA-36], Rep. Joyce, John [R-PA-13], Rep. Tlaib, Rashida [D-MI-12], Rep. Smith, Adrian [R-NE-3], Rep. Rutherford, John H. [R-FL-5], Rep. Veasey, Marc A. [D-TX-33], Rep. Rulli, Michael A. [R-OH-6], Rep. Owens, Burgess [R-UT-4], Rep. Miller, Carol D. [R-WV-1], Rep. Bynum, Janelle S. [D-OR-5], Rep. Neguse, Joe [D-CO-2], Rep. McBride, Sarah [D-DE-At Large], Rep. Yakym, Rudy [R-IN-2], Rep. Sewell, Terri A. [D-AL-7]
Recent Actions
- 2025-04-24: 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.
- 2025-04-24: 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.
- 2025-04-24: Introduced in House
- 2025-04-24: Introduced in House
Bill Versions
- To amend title XVIII of the Social Security Act to limit the coinsurance amount for certain services furnished in an ambulatory surgical center. — issued 2025-04-24 — PDF (2 pages)