S2355-119

What This Bill Does

The reported Patients Deserve Price Tags Act consolidates provider-price rules in a new Public Health Service Act section. Beginning January 1 of the first year that starts at least one year after enactment, hospitals, covered laboratories, imaging providers, and ambulatory surgical centers must publish free machine-readable standard charges quarterly when information changes. Disclosures include billing codes, gross charges, discounted cash prices, payer-specific negotiated dollar amounts and underlying formulas, de-identified negotiated ranges, facility fees where applicable, and names and addresses of owners, controlling persons, management-services organizations, and significant equity investors. Hospitals must also publish consumer-friendly shoppable-service information, obtain senior-official attestations, and undergo annual compliance review. Civil penalties scale by bed count and duration, persistent hospital violations can add $500,000 to $10 million, and a noncompliant hospital can be barred from extraordinary collection actions for debt incurred during noncompliance. Laboratories, imaging providers, and surgical centers face corrective plans and penalties up to $300 per day. Health plans and insurers must give enrollees in-network rates, out-of-network allowed amounts, estimated cost sharing, accumulator status, volume limits, and utilization-management information through a free real-time tool. They must publish quarterly machine-readable in-network, drug, and out-of-network rate files plus ownership information; HHS must audit at least 50 files annually, Labor at least 250, and the agencies must report results to Congress. Service contracts for employer plans with at least 50 workers or participants may not block fiduciary access within 15 days to claims, payment support, pricing methods, fees, overpayments, audit rights, ownership, or de-identified aggregate data. HIPAA and civil-rights protections remain, data may be used only for plan administration, and specified files must use standard electronic formats at no cost. Covered service providers must also report quarterly reimbursement formulas, rebates, fees, alternative compensation, subcontractor payments, and ownership; inconsistent contractual restrictions are void and HHS must act on known violations. The bill preserves nonconflicting state transparency laws. It expands advance and final explanations of benefits, holds patients harmless for certain charges substantially above advance estimates unless unforeseen medically necessary care explains the difference, and requires facility-fee and discrepancy information. Providers requesting payment must notify patients of the right to a free itemized bill, provide requested billing records within 30 days, disclose language and charity-care help, and refrain from billing or collection when required notice is missing or charges exceed disclosed prices without qualifying documentation. Violations can draw $10,000 penalties. ERISA and tax-code amendments apply the requirements across regulated plans, and open-ended appropriations beginning in fiscal year 2026 fund HHS and Labor implementation and enforcement. Compared with the introduced bill, the reported text changes provider start dates and update schedules, adds ownership and facility-fee disclosures, limits core plan-data access to plans with at least 50 workers or participants, adds stronger hold-harmless and collection protections, makes detailed bills available on request rather than automatically in every case, and adds explicit enforcement funding.

Who Benefits and How

Patients, self-pay consumers, people with limited English proficiency, plan participants, employer plan fiduciaries, and state regulators gain comparable price files, ownership information, real-time cost estimates, utilization-management details, complete claims data, itemized benefits, charity-care information, and enforceable rights when final charges exceed disclosed prices. Patients of noncompliant hospitals receive protection from specified extraordinary collection actions. Employer plan sponsors gain timely access to claims, contracts, payment formulas, fees, rebates, overpayments, ownership relationships, and audit rights that can reveal waste or conflicts. Healthcare comparison services, researchers using de-identified data, HHS, Labor, Treasury, Congress, and state insurance agencies gain standardized data and recurring audit results.

Who Bears the Burden and How

Hospitals, laboratories, imaging centers, ambulatory surgical centers, healthcare owners, insurers, third-party administrators, pharmacy benefit managers, provider networks, and billing offices must build files and tools, disclose negotiated rates and formulas, report ownership and remuneration, attest to accuracy, answer data requests, protect privacy, issue notices, and change contracts. Noncompliance can trigger daily penalties, multimillion-dollar persistent-violation penalties, $10,000 billing penalties, corrective plans, void terms, and collection restrictions. HHS, Labor, Treasury, inspectors general, and state regulators must issue rules, define formats, conduct hundreds of audits, investigate violations, enforce deadlines, provide technical assistance, and report to Congress. Federal taxpayers fund implementation indefinitely. Smaller employer plans gain less direct data-access protection because the reported bill applies its core contract rule at a 50-worker or 50-participant threshold.

Key Provisions

• Requires quarterly provider disclosure of cash, gross, negotiated, ownership, facility-fee, and shoppable-service information.
• Establishes annual audits, daily civil penalties, persistent hospital penalties, and collection limits for noncompliance.
• Requires free real-time plan cost tools and public machine-readable in-network, drug, and out-of-network rate files.
• Bars covered service contracts from withholding claims, pricing formulas, fees, ownership, audit rights, and payment support from large plans.
• Requires quarterly disclosure of service-provider rebates, remuneration, subcontractor payments, and alternative compensation.
• Protects nonconflicting state transparency laws and existing health-data privacy and civil-rights rules.
• Provides itemized benefit and billing information plus hold-harmless and collection protections for certain excess charges.
• Authorizes continuing HHS and Labor appropriations for implementation and enforcement beginning in fiscal year 2026.