Image by Jacqui from PixabayThe Medicare Beneficiary Copay Fairness Act is gaining momentum.
Rep. Marc Veasey (D-Texas) has joined as one of the newest cosponsors of the Act.
The bipartisan bill was introduced on April 24 and addresses a Medicare payment rule for ambulatory surgery centers (ASCs), where Medicare Part B beneficiaries pay a standard 20% coinsurance for procedures at both ASCs and hospital outpatient departments (HOPDs).
However, only HOPD copays are limited by the inpatient deductible, which is currently $1,676 for 2025 and will increase to $1,736 for 2026. This means ASC patients could face higher out-of-pocket costs for nearly 183 procedures, even when opting for the often lower-cost ASC setting.
For low-income Medicare Part B beneficiaries who cannot afford Medigap, Medicare’s supplemental insurance, this loophole may cause them to pay a higher copay for a procedure in an ASC than they would for the same procedure in an HOPD.
The Medicare Beneficiary Copay Fairness Act addresses this by increasing the current ASC cap, ensuring that a beneficiary’s out-of-pocket costs at an ASC are the same as at an HOPD for affected procedures.
The bill was referred to the House Energy and Commerce and House Ways and Means Committees but has not yet been included in committee markup, according to David Opong-Wadee, the Ambulatory Surgery Center Association’s (ASCA) manager of legislative and political affairs.
“We’ve had productive meetings with the majority and minority health staff of the committees of jurisdiction, and they are interested in the legislation,” Opong-Wadee told Ambulatory Surgery Center News.
Senators Bill Cassidy (R-La.) and Richard Blumenthal (D-Conn.) introduced companion legislation with the same name in the Senate on May 15.
Opong-Wadee said ASCA is shifting its focus to seeking cosponsorships for the Senate companion bill until the end of the year. However, the belief is that the bill’s greatest potential currently lies in the House.
“There is still no official Congressional Budget Office (CBO) cost estimate,” Opong-Wadee said. “Therefore, having the bill scored by CBO is the most immediate and necessary procedural hurdle for any further legislative action, such as a committee markup. Increasing support for the bill through additional cosponsors is helpful.”
Congressional outlook
According to Opong-Wadee, feedback from members of Congress and staff regarding both bills highlights two main bipartisan themes: fairness for seniors and cost efficiency for Medicare.
“Supporters emphasize that the current policy is unfair because it exposes Medicare beneficiaries who use lower-cost ASCs to potentially higher out-of-pocket costs – up to 20% of the total procedure cost – compared to going to a more expensive HOPD,” Opong-Wadee explained. “This is especially significant for low-income seniors without supplemental insurance.”
Supporters believe the bill ultimately benefits both Medicare and taxpayers.
“ASCs are projected to be more cost-effective sites of care, and removing the copay penalty would encourage their use, potentially saving Medicare billions in the long run,” Opong-Wadee said.
The strong bipartisan support in both the House and Senate indicates that the policy is seen as a common-sense technical fix to a Medicare payment disparity, rather than a contentious partisan issue, according to Opong-Wadee.
“This makes the bill a strong candidate for inclusion in a broader health package,” he said. “Moreover, the diversity of current cosponsors represents a myriad of geographical and political ideologies.”
As of November, with the bill stalled at the “introduced” stage in both chambers and the focus still on Affordable Care Act subsidies and broader health care package debates, it is highly unlikely to pass this year. The CBO score is the next mandatory step, Opong-Wadee said.
Even so, increased support for the companion Senate bill through the end of the year boosts its chances.
The bill is well-suited to be attached to a must-pass, year-end legislative vehicle in 2026 because of its clear, non-partisan, patient-friendly policy goal, bipartisan committee sponsors in both chambers, and a policy argument that it could save Medicare money in the long run.
According to Opong-Wadee, the way forward depends on getting a favorable CBO score and securing a spot on a legislative vehicle next year. The current focus on the Senate will be vital in helping the bill reach a point where leadership in both chambers is prepared to move it forward.
“It is difficult to predict this current Congress, but ASCA remains hopeful and prepared to act if an opportunity arises for the bill to advance,” Opong-Wadee stated. “ASCA will focus its efforts on building support for the companion bill in the Senate before the end of this year and at the start of next year. We are also working on introducing a second bill.”
