Some maximum coinsurance amounts are so far above the applicable minimum coinsurance amount that it will take years of increases in the APC Rate before the minimum coinsurance amount will approach the maximum coinsurance amount. It would not be surprising to see additional legislation reducing these time frames in response to lobbying from the Medicare population. Not all of the actual coinsurance amounts will take this long to equal the minimum coinsurance amount. Some APCs already have a minimum coinsurance amount equal to the maximum coinsurance amount. Other APCs should reach this point within a few years.
Several procedures are exempt entirely from the maximum coinsurance amount program.
Medicare coverage for screening sigmoidoscopies and screening colonoscopies was mandated by Congress prior to the issuance of the OPPS final rule. The APC Rates and coinsurance amounts in the above examples are based on national unadjusted numbers. The actual amounts will vary based on the wage area in which each hospital is located. In addition to the annual adjustments to the APC Rates, the OPPS final rule provides for additional payments to hospitals for outlier cases and for certain medical devices, drugs and biologicals. These payments will be in addition to the APC Rate but will not affect the coinsurance amounts.