Image by Storme Kovacs from PixabayThe U.S. Centers for Medicare & Medicaid Services (CMS) floated big changes to the outpatient surgery landscape when the agency shared its 2026 proposed payment rule for ambulatory surgery centers (ASCs) on July 15.
To recap, CMS’ proposal included doing away with the Medicare Inpatient Only List (IPO), adding to the ASC Covered Procedures List (ASC-CPL) and giving ASCs a relatively modest payment adjustment. CMS likewise proposed changes to the Ambulatory Surgical Center Quality Reporting (ASCQR) program.
“We’re excited by CMS’s proposal to eliminate the inpatient-only list and expand the [ASC-CPL], giving more patients access to high-quality, cost-effective care in outpatient settings,” Heather Richards, chief financial officer of Atlas Healthcare Partners, said at the time. “This proposal rightly prioritizes physician judgment in determining the most clinically appropriate site of care, ensuring decisions are based on patient needs rather than outdated policy restrictions.”
CMS will share its 2026 final payment rule for ASCs this fall, likely in early November.
In the meantime, federal health care policymakers will begin to review the thousands of public comments that ASC stakeholders submitted regarding the July proposal. CMS received more than 3,900 comments on its proposed rule during the standard commenting period, which officially closed on Sept. 15.
Many of those comments supported the broad strokes of CMS’ plan.
“The expansion of the [ASC-CPL] and phasing out of the [IPO] list reflects a positive development in acknowledging how advances in surgical techniques and anesthesia reinforce safe outpatient care,” one commenter who was supportive of CMS’ stance wrote. “CMS should ensure robust beneficiary protections and closely monitor data as these changes are implemented to prevent inappropriate site-of-service shifts driven exclusively by reimbursement differences.”
While the bulk of the submitted comments came from individuals, key ASC industry groups also submitted.
In its comments, for example, the Ambulatory Surgery Center Association (ASCA) voiced support for CMS’ proposal to expand the list of procedures allowed to be performed in ASCs.
“ASCA agrees with CMS that clinicians are the stakeholders best suited to determine the appropriate site of service for their patients,” ASCA said in a statement shared with ASC News. “ASCA’s comments also reflected ongoing advocacy for continued alignment of inflationary update factors between ASCs and HOPDs and the elimination of the budgetary adjustment that continues to severely depress rates for important Medicare procedures like cataract removals.”
‘The right thing to do’
Two dozen state ASC associations expressed their views on CMS’ 2026 proposed payment rule. In a joint letter, the organizations started by thanking CMS for its continued use of the hospital market basket as the annual update mechanism for ASC payments.
“The ASC community has long urged CMS to adopt the same update factor for both the ASC and OPPS payments, and we were gratified that the first Trump administration took this necessary step toward better alignment of the payment systems by piloting the use of the hospital market basket for ASCs beginning in 2019,” they wrote in the letter.
At the same time, however, the ASC industry groups called for the elimination of the ASC weight scalar – or at least a more balanced approach to setting payment rates across settings.
“While this would be both the right thing to do and save billions of dollars for the Medicare program, we also propose an alternative: that CMS combine the OPPS and ASC utilization and mixes of services to establish a single weight scalar,” the letter continued. “In other words, CMS could apply a single budget neutrality calculation to the OPPS and ASC payment systems. By incorporating the ASC volume into the OPPS weight scalar calculations, CMS would further the alignment of the payment systems and more accurately scale for outpatient volume across both sites of service.”
The organizations also asked CMS to include certain cardiology codes – electrophysiology studies and ablations codes 93619, 93620 and 93642, and cardioversion and transesophageal echocardiogram (TEE) codes 92960, 93312 and 93318 – on the ASC-CPL for 2026.
While many of the comments supported shifting procedures into the outpatient setting, other commenters took the opportunity to point out important cost considerations.
“If CMS does expand the ASC-CPL to include nearly every procedure, with the goal of increasing patient access, it is incumbent on CMS to address the patient financial liability differential between hospital services and ASC services,” a commenter explained. “As you know, there is no cap on the patient’s liability for coinsurance for ASC services as exists with hospital outpatient services where the cap is the Part A deductible. This means that there will be 270 procedures where the patient without a supplement will be required to pay from $1,684 up to $8,373 out of pocket.”
This is an issue that ASCA has repeatedly called attention to via its support of the Medicare Beneficiary Co-Pay Fairness Act.
In terms of its proposed changes to ASCQR, CMS is seeking to remove measures around COVID-19 vaccination status and social determinants of health (SDoH). Generally, the ASC industry has been supportive of the proposal.
“COVID-19 data collection should be eliminated due to the fact that it is no longer mandatory to be vaccinated,” another commenter wrote. “Collecting Social determinants of health in the ambulatory surgery space is not information that an elective procedure environment can act on. Social workers are not employed in this setting and normally this setting is rarely a repeat process for the public.”
Of course, not all commenters supported the idea of shifting more procedures into the outpatient setting.
“[In] this rule you propose to add over 600 procedures to the ASC CPL, including almost 300 that are also being removed from the inpatient only list, meaning they were never performed as outpatient in the hospital setting,” one such commenter wrote. “That is dangerous and should be reconsidered.”
Another topic that came up frequently in comments: The NOPAIN Act.
Signed into law in December 2022, the NOPAIN Act is federal legislation aimed at reducing opioid use by increasing access to non-opioid pain treatments, especially in Medicare.
“The 2022 NOPAIN Act passed Congress with bipartisan support and a clear purpose: to expand access to non-opioid pain treatments, reduce opioid exposure and combat addiction,” one commenter wrote. “Yet CMS’s narrow interpretation of the law is restricting access to FDA-approved alternatives and undermining its intent.”
“Everyone in America should have the same access to medical treatment with no difference depending on insurance plans,” another comment on the topic explained. “Unfortunately, the current CMS interpretation of the NOPAIN Act, which excludes many non-opioid pain treatments for Medicare patients, makes it hard for patients who need something for pain aside from an opioid.”
