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Senate Joins House in Introducing Landmark Medicare Copay Fairness Act

The bill addresses a key payment disparity

BY DAVID OPONG-WADEE | MAY 15, 2025

Momentum continues to build for fairer Medicare coinsurance rates across sites of care. Senators Richard Blumenthal (D-CT) and Bill Cassidy, MD (R-LA), introduced the Medicare Beneficiary Co-Pay Fairness Act of 2025 today in the Senate. ASCA strongly endorses this pivotal legislation, which mirrors a bill introduced in the House of Representatives just weeks prior on April 24 by Representatives Mike Kelly (R-PA), Robert Menendez Jr. (D-NJ), Troy Balderson (R-OH) and John Larson (D-CT).

The bipartisan Senate introduction of this bill marks a significant step in addressing a key Medicare disparity. While Part B beneficiaries face a standard 20 percent copay for procedures in both ASCs and hospital outpatient departments (HOPD), only HOPD copays are capped at the inpatient deductible, which is $1,676 for 2025. This leaves ASC patients exposed to potentially higher out-of-pocket costs for approximately 183 procedures, even when choosing the often more efficient and lower-cost ASC setting.

“If your grandmother depended on Medicare for life-saving treatment, you would not want to hear that Medicare was cutting corners,” Senator Cassidy says. “This bill makes costs fairer for patients while keeping the quality of care high.”

ASCA Chief Executive Officer Bill Prentice underscores the urgency of this legislative action. “Surgery centers are the high-quality and cost-effective site of service for an ever-growing number of outpatient procedures,” Prentice says. “The current absence of a limit on Medicare beneficiary out-of-pocket costs in ASCs, despite one being in place for procedures performed in hospitals, unintentionally drives patients to higher-cost care settings.”

The current policy burdens beneficiaries with potentially higher expenses and creates an illogical incentive within the Medicare system. When the cap is triggered in an HOPD, Medicare effectively covers the difference, ensuring that the hospital receives the remainder after a patient has paid their capped amount. Given that Medicare’s reimbursement rates for procedures in HOPDs are consistently higher than those for the same procedures in ASCs, the lack of an ASC coinsurance cap inadvertently steers patients toward the more expensive option, adding unnecessary strain to the Medicare program.

The Medicare Beneficiary Co-Pay Fairness Act of 2025 offers a straightforward solution by extending the existing HOPD coinsurance cap to procedures performed in ASCs. This change would empower beneficiaries to choose the appropriate site of care without facing undue financial penalties.

With more than 6,300 Medicare-certified ASCs operating nationally, providing a wide array of outpatient surgical services, the potential for savings is substantial. An analysis by KNG Health Consulting projected that ASCs could save Medicare $73.4 billion between 2019 and 2028 due to their inherent efficiency and lower cost structure. By removing the copay disparity, this legislation will pave the way for greater utilization of these cost-effective centers, benefiting patients and the entire Medicare system. The strong bipartisan support in the House and Senate signals a promising path forward for this crucial legislation.

Write David Opong-Wadee with any questions.