H.R. 5582 — Patients Deserve Price Tags Act

This section revises hospital price transparency requirements under Section 2718(e) of the Public Health Service Act by requiring each hospital to compile and publicly disclose on a monthly basis, free of charge and without subscription—(1) all standard charges for each item and service provided in inpatient and outpatient settings; and (2) such information in a consumer-friendly format including at least 300 shoppable services (i.e., services that can be scheduled in advance, such as those specified by the Centers for Medicare & Medicaid Services) through December 31, 2026, after which all shoppable services must be included. (As background, these requirements build on existing rules intended to enable consumers to compare hospital prices for services.) Standard charges must include (i) a plain-language description with applicable billing codes (e.g., CPT, HCPCS); (ii) gross charge as a dollar amount; (iii) discounted cash price as a dollar amount (or minimum cash price accepted from self-pay patients if unavailable), which the hospital must accept as payment in full, plus a link to the hospital's charity care policy for consumer-friendly disclosures; (iv) payer-specific negotiated charges as dollar amounts clearly associated with each third-party payer and plan, including any algorithms, formulas, or contract terms used to derive them; (v) de-identified maximum and minimum negotiated charges as non-zero dollar amounts; and (vi) other Secretary-required information to enhance accuracy and comparability. Not later than January 1, 2026, the Secretary must establish uniform methods and formats for disclosures, including machine-readable spreadsheets for standard charges. Price estimator tools do not satisfy these requirements. The Secretary must monitor hospital compliance at least annually in consultation with the Inspector General, and a senior hospital official (e.g., CEO or CFO) must attest to the accuracy and completeness of disclosures. (Thus, the changes expand disclosure frequency, detail, and accessibility compared to prior rules, which generally required less granular, less frequent posting of charges.)

This section requires applicable laboratories to publicly disclose on their websites, beginning July 1, 2027, prices for each specified clinical diagnostic laboratory test they furnish—including (1) plain language descriptions with applicable billing codes (e.g., CPT, HCPCS), (2) gross charges, (3) discounted cash prices (or minimum cash prices accepted from self-pay patients over prior three years, accepted as payment in full from cash-paying patients), (4) payer-specific negotiated charges with contract details, (5) de-identified minimum and maximum negotiated charges, and (6) additional information as required by the Secretary—updated monthly if changed and encompassing ancillary services (e.g., specimen collection). Directs the Secretary to establish by January 1, 2027, a uniform machine-readable format for such disclosures. Authorizes civil monetary penalties of up to $300 per day (increasable after 2027) for noncompliance following notice and a 90-day cure period, with application of specified Social Security Act enforcement provisions, and requires technical assistance for compliance.

This section requires each provider of services or supplier furnishing a specified imaging service—other than one for which standard charges are disclosed by a hospital under Section 2718(e)—to publicly post specified pricing information for each such service on its website beginning July 1, 2027, and to update the information annually. (Section 2718 generally requires hospitals and health plans to disclose standard charges to promote price transparency.) The required information includes (1) a plain language description with applicable billing codes (e.g., CPT, HCPCS); (2) the gross charge; (3) the discounted cash price (or, if unavailable, the minimum cash price accepted from self-pay patients over the prior three years, with a link to the charity care policy, and acceptance as payment in full from cash-paying patients); (4) payer-specific negotiated charges by third-party payer and plan name for inpatient and outpatient settings (including any algorithms, formulas, or contract terms used); (5) de-identified maximum and minimum negotiated charges; and (6) additional information required by the Secretary of Health and Human Services to improve accuracy and comparability. The Secretary must specify by January 1, 2027, a uniform machine-readable format (e.g., spreadsheet) for disclosures; monitor compliance through rulemaking; and enforce violations with civil monetary penalties of up to $300 per day (potentially increased after 2027) following notice, a 45-day corrective action period, and an additional 90-day compliance window.

This section requires each specified ambulatory surgical center to publicly disclose, without subscription and free of charge beginning July 1, 2027, (1) machine-readable lists of standard charges for all items and services provided, including descriptions with codes, gross charges, discounted cash prices (accepted as payment in full from cash-paying patients), payer-specific negotiated charges (including formulas and contract terms), and de-identified maximum and minimum negotiated charges; and (2) consumer-friendly price information for at least 300 shoppable services (including all Centers for Medicare & Medicaid Services-specified shoppable services furnished by the center or indications if not furnished, plus additional center-selected shoppable services). The Secretary of Health and Human Services must establish uniform methods and formats for these disclosures by January 1, 2027 (ensuring machine-readable formats, accessibility, and usability, with periodic updates); price estimator tools do not satisfy these requirements; the Secretary must monitor compliance annually in consultation with the HHS Inspector General; and, for noncompliance, the Secretary must notify the center within 30 days of determination.

This section revises transparency requirements for health plans offered through Affordable Care Act (ACA) Exchanges (i.e., health insurance marketplaces established under ACA §1311) by requiring self-service tools—internet-based, real-time, and regularly updated—to disclose, for any item or service by provider: (1) in-network rates (previously limited to participating providers); (2) out-of-network maximum allowed amounts; (3) enrollee cost-sharing amounts (including deductibles, copayments, and coinsurance, calculated using out-of-network maximums where applicable); (4) accumulated progress toward deductibles or out-of-pocket maximums; (5) accrued amounts toward frequency or volume limits; and (6) prior authorization or similar requirements; with an option for paper or phone disclosure at no cost to the enrollee and a member-harmless provision for tool inaccuracies (Thus, consumers can shop for care with detailed, provider-specific pricing before services are furnished). It further requires each health plan, beginning January 1, 2027 and monthly thereafter, to submit to the Exchange, HHS Secretary, state insurance commissioner, and the public: (1) in-network rates (by CPT, HCPCS, DRG, NDC, or similar codes) for all covered items and services with participating providers (excluding those with no or expected-no claims); and (2) for covered drugs (by NDC, J-code, or similar), both in-network rates and historical net prices paid (net of rebates, discounts, and concessions) over the prior 90 days.

This section amends the ERISA statutory exemption for reasonable service contracts with parties in interest (29 U.S.C. 1108(b)(2)) to require that, for group health plans, no contract or arrangement (including renewals) with a covered service provider—i.e., health care provider or facility, provider network or association, third-party administrator, or pharmacy benefit manager—is reasonable unless it (1) allows the responsible plan fiduciary access to all claims and encounter data, supporting documentation (e.g., medical records), and related information to ensure plan compliance and payment accuracy; and (2) prohibits (i) unreasonable limits or delays on access (not later than 15 days, as determined by the Secretary), (ii) limits on data volume during audits, (iii) nondisclosure of value-based or capitated pricing terms (e.g., payment formulas, quality measures, incentives), (iv) limits on overpayment disclosures or recovery terms, (v) restrictions on auditor selection or audit scope/frequency, (vi) barriers to daily batch data access, (vii) nondisclosure of administrative fees (e.g., repricing or access fees), (viii) limits on addressing suspect payments, or (ix) restrictions on public disclosure of de-identified or aggregate data. (As background, ERISA prohibits fiduciaries from certain transactions with parties in interest absent an exemption; section 408(b)(2) exempts reasonable service arrangements to enable plans to obtain necessary services without fiduciary conflict.) The section further requires such providers and plans to handle data consistent with HIPAA privacy and security regulations (without modifying existing HIPAA requirements or imposing new ones); limits plan disclosures to HIPAA-compliant uses; and mandates data in specified electronic formats at no cost (e.g., ASC X12N 837 for institutional/professional/dental claims, NCPDP for pharmacy claims, ASC X12N 835 for remittance advice), as unmodified copies from providers.

This section adds a new section 726 to ERISA (in subpart B of part 7 of subtitle B, 29 U.S.C. 1021 et seq.) to establish oversight of health plan service providers (i.e., health care providers, networks, third-party administrators, pharmacy benefit managers, and similar entities) for group health plans. For plan years beginning two years after enactment, it prohibits any agreement with a group health plan, plan sponsor, plan administrator, business associate, or health insurance issuer that limits or delays disclosure of specified information, and it requires such service providers to disclose the following information quarterly at no cost, consistent with HIPAA privacy and security rules: (1) information described in section 724(a)(1)(B) of ERISA; (2) contractual and subcontractual methodologies, pricing, fee schedules, and adjustments used to determine provider reimbursements; (3) total amounts received or expected from rebates, fees, discounts, and other remuneration (including escrows and variance accounts) for claims and services; (4) total amounts paid or expected to be paid in such rebates, fees, and remuneration for services; and (5) payment and reconciliation data for alternative arrangements (e.g., accountable care organizations, value-based programs, bundled payments). It limits redisclosure of such information by group health plans to the disclosing entity, business associates, or as permitted under the HIPAA Privacy Rule; requires health insurance issuers to share equivalent information with group health plans; and deems failure to disclose a violation of ERISA subject to Secretary enforcement. (Thus, it enhances group health plan transparency into service provider finances and reimbursements.) This section also amends ERISA section 1132(a)(6) (29 U.S.C. 1132(a)(6)) to authorize the Secretary to collect civil penalties under new paragraphs (13) and (14) of section 1132(c).

This section limits the preemptive effect of sections 2 through 5 on state laws establishing, implementing, or continuing requirements or prohibitions related to health care price transparency—including for hospitals, clinical diagnostic laboratory tests, imaging services, and ambulatory surgical centers—to the extent of any direct conflict. This section does not affect group health plans under the Employee Retirement Income Security Act of 1974 or alter the application of ERISA's general preemption provision.

This section amends the No Surprises Act protections in the Public Health Service Act (PHSA), Internal Revenue Code (IRC), and Employee Retirement Income Security Act (ERISA) (1) to revise the advanced explanation of benefits for emergency services—previously a good faith estimate of the plan's responsibility—to instead require such estimate to include a plain language description of each item or service and all applicable billing codes (including modifiers) using standard, clearly identified code sets; and (2) to require group health plans and health insurance issuers offering group or individual coverage to provide participants, beneficiaries, or enrollees (via mail or electronic means), within 45 days of receiving any payment request for an item or service, a notification in clear language and substantially the same format as the advanced explanation—including the provider or facility's participating status, itemized plain language service descriptions, applicable billing codes (including modifiers), plan payment amounts, cost-sharing amounts (as of notification date), progress toward financial responsibility limits (including deductibles and out-of-pocket maximums, as of notification date), and service sites—for plan years beginning on or after January 1, 2026. The section directs the Secretary to implement these requirements through notice-and-comment rulemaking under 5 U.S.C. §553.

This section requires health care providers and facilities to furnish patients with a written itemized bill—including plain-language descriptions, billing codes, prices and billed amounts, payments received, language-assistance information, a contact for bill inquiries, and charity care application instructions—within 30 days after receiving final third-party payment for provided items or services (including telehealth). It prohibits collection actions against patients absent such a bill or if billed amounts exceed federally required price transparency disclosures or good faith estimates unless the provider documents medical necessity due to unforeseen complications (with burden of proof on the provider and the estimate otherwise binding); authorizes civil penalties up to $10,000 per violation; creates a presumption of excessive charges in patient-provider disputes for noncompliance; and directs the Secretary to implement via notice-and-comment rulemaking.