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LUGPA Policy Brief: Capping Coinsurance for Ambulatory Surgical Center (ASC) Services

May 2025 

Medicare beneficiaries face a significant inconsistency in out-of-pocket costs for outpatient care. While beneficiaries pay 20% coinsurance for services in both Ambulatory Surgical Centers (ASCs) and Hospital Outpatient Departments (HOPDs), HOPD coinsurance is capped at the inpatient deductible ($1,676 in 2025), but no such limit applies to ASC services.

This disparity can lead to higher out-of-pocket expenses for patients choosing ASCs, despite ASCs providing equivalent care at a lower cost to Medicare. Addressing this inequity is essential to ensure fair and affordable access to high-value care.

For approximately 150 procedures, beneficiaries may face higher coinsurance in ASCs than in HOPDs, discouraging the use of these more efficient care settings and creating an unfair financial burden on patients.

The Medicare Beneficiary Co-Pay Fairness Act would correct this disparity by:

  • Capping coinsurance for ASC facility services at the inpatient deductible, consistent with HOPD policy.
  • Reimbursing ASCs for the difference between the capped amount and the standard 20%, maintaining financial neutrality.
  • Applying the change to services provided on or after January 1, 2026.

Why It Matters

  • Protects Patients: Many beneficiaries without supplemental insurance—disproportionately from underserved communities—face significant financial barriers.
  • Encourages Smart Spending: ASCs deliver high-quality, cost-effective care. Current policy drives patients toward more expensive HOPDs simply to reduce out-of-pocket costs, increasing Medicare’s financial burden.
  • Advances Site-Neutral Reform: Aligning patient cost-sharing is a necessary step in broader bipartisan efforts to eliminate arbitrary payment differences between care settings.

LUGPA supports the Medicare Beneficiary Co-Pay Fairness Act as a targeted, non-disruptive solution to enhance affordability and access to high-value care. Many LUGPA practices operate ambulatory surgical centers (ASCs) that deliver advanced treatments at lower costs than traditional hospital settings. By capping coinsurance for ASC services, this policy ensures Medicare beneficiaries are not financially burdened for choosing cost-effective, high-quality care. LUGPA urges Congress to swiftly pass this legislation to safeguard patients, broaden access to equitable care, and advance fiscally responsible healthcare delivery.

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