S. 2355 — 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 make public, on a monthly basis without subscription or charge and in formats specified by the Secretary of Health and Human Services (HHS), (1) all standard charges for each item and service provided in inpatient and outpatient settings; and (2) consumer-friendly standard charge information covering at least 300 shoppable services (including all CMS-specified shoppable services furnished by the hospital, plus additional hospital-selected ones, or an indication if a CMS-specified service is not furnished) through December 31, 2026, after which all shoppable services must be included. Standard charges must include (i) plain-language descriptions with applicable billing codes (e.g., CPT, HCPCS, DRG, NDC); (ii) gross charges; (iii) discounted cash prices (or minimum cash price accepted from self-pay individuals if unavailable), which the hospital must accept as payment in full from cash-paying patients, plus—for consumer-friendly disclosures—a link to the hospital's charity care policy; (iv) payer-specific negotiated charges by third-party payer and plan name, including any algorithms, formulas, or contract terms used to determine them; (v) de-identified maximum and minimum negotiated charges; and (vi) additional information required by the Secretary to improve accuracy and comparability. For bundled, per diem, episodic, or similar arrangements, such information must be disclosed as determined appropriate by the Secretary. (As background, these requirements build on prior rules intended to enable consumers to compare hospital prices across payers and settings.) HHS must establish uniform methods and formats by January 1, 2026—including machine-readable spreadsheets for standard charges—to ensure accessibility and usability, with updates as needed in consultation with stakeholders. Price estimator tools do not satisfy these requirements. HHS, in consultation with its Inspector General, must monitor hospital compliance at least annually, and a senior hospital official (e.g., CEO or CFO) must attest to the accuracy and completeness of disclosures.

This section requires applicable laboratories, beginning July 1, 2027, to publicly post on their websites and update monthly (if changed) specified information on clinical diagnostic laboratory tests, including (1) plain-language descriptions with applicable billing codes (e.g., CPT, HCPCS); (2) gross charges; (3) discounted cash prices (or minimum cash prices over prior three years, accepted as full payment from cash-paying patients); (4) payer-specific negotiated charges (including algorithms or formulas used); (5) de-identified maximum and minimum negotiated charges; and (6) additional information as required by the Secretary of Health and Human Services (HHS). Such disclosures must cover ancillary services (e.g., specimen collection, transport) customarily furnished with the tests and use a uniform machine-readable format (e.g., spreadsheet) established by HHS by January 1, 2027. For noncompliance, HHS may impose civil monetary penalties of up to $300 per day (increasable after 2027) following a 30-day notice and 90-day cure period.

This section requires each provider of services or supplier furnishing a specified imaging service—other than one for which standard charges and prices are already made public by a hospital under subsection (e)—to post specified pricing information on a public website beginning July 1, 2027, and to update it annually. The required information includes (1) a plain language description with applicable billing codes; (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, along with a charity care policy link, with acceptance as payment in full from cash-paying patients); (4) payer-specific negotiated charges (including algorithms, formulas, or contract terms used to derive them) for inpatient and outpatient settings; (5) de-identified maximum and minimum negotiated charges; and (6) additional information as required by the Secretary to improve accuracy and comparability. This section further directs the Secretary of Health and Human Services, by January 1, 2027, to establish a uniform, machine-readable format (e.g., spreadsheet) for such disclosures, in consultation with stakeholders; to monitor compliance through notice-and-comment rulemaking; and to enforce via notifications, required corrective action plans, and civil monetary penalties of up to $300 per day (potentially increased for violations after 2027) for ongoing noncompliance beginning 90 days after notification.

This section requires specified ambulatory surgical centers, beginning July 1, 2027, to publicly disclose without charge—in machine-readable format for standard charges and consumer-friendly format for shoppable services—(1) lists of standard charges for each item and service provided, including descriptions with codes, gross charge, discounted cash price (which must be accepted as payment in full from cash-paying patients), payer-specific negotiated charges (including contract formulas), and de-identified maximum and minimum negotiated charges; and (2) prices for at least 300 shoppable services (including all CMS-specified shoppable services or an indication if not provided, plus additional ASC-selected services). Directs the Secretary of Health and Human Services (HHS), by January 1, 2027, to establish uniform methods and formats for these disclosures (ensuring accessibility and usability, with updates as needed); clarifies that price estimator tools do not satisfy these requirements; and requires HHS, in consultation with the Inspector General, to monitor compliance at least annually and enforce via notice of failure (with further enforcement upon request of [text cuts off]).

This section revises Affordable Care Act (ACA) Exchange requirements for health plans to disclose coverage information for specific items and services via a self-service internet tool (or, at enrollee option, paper or phone disclosure), specifying the following details: (1) in-network rates or out-of-network maximum allowed amounts; (2) enrollee cost-sharing (including deductibles, copayments, and coinsurance); (3) accumulated amounts toward deductibles, out-of-pocket maximums, or frequency/volume limits; and (4) prior authorization or similar requirements. The self-service tool must provide real-time, accurate responses searchable by provider, billing code, or descriptive term; cover participating and non-participating providers; and hold enrollees harmless for charges exceeding tool estimates. (Thus, enrollees can more easily shop for and compare plan coverage and costs prior to receiving care.) The section further requires health plans, beginning January 1, 2027 and monthly thereafter, to submit to the Exchange, HHS Secretary, and state insurance commissioners—and make publicly available—(1) all in-network rates (by CPT, HCPCS, DRG, NDC, or similar codes) for covered items and services with participating providers (identified by NPI, excluding low/no-claim providers); and (2) for covered drugs (by NDC, J-code, etc.), in-network rates and historical net prices (net of rebates, etc.) paid during the prior 90 days.

This section amends the Employee Retirement Income Security Act (ERISA) exemption for reasonable service contracts under section 408(b)(2) by adding subparagraphs (C) through (F), which establish new conditions applicable to contracts or arrangements between group health plans and covered service providers (i.e., health care providers or facilities, provider networks or associations, third-party administrators, or pharmacy benefit managers). To qualify as reasonable and exempt from ERISA prohibited transaction rules, such contracts must (1) allow responsible plan fiduciaries access to all claims and encounter data, supporting documentation (including medical records), and related information to ensure plan compliance and payment accuracy; and (2) prohibit specified limitations, including delays exceeding 15 days in providing data, volume restrictions on audits, limits on disclosing value-based or capitated pricing terms (e.g., payment formulas, quality measures, incentives), restrictions on auditor selection or overpayment disclosures, barriers to daily batch access, nondisclosure of administrative fees, limits on addressing suspect payments, or restrictions on de-identified data sharing. The section further requires data exchanges to use specified HIPAA transaction standards (e.g., ASC X12N 837 for claims, NCPDP for pharmacy, ASC X12N 835 for remittance advice) as unmodified electronic files at no cost to the plan and mandates compliance with HIPAA privacy and security regulations for all parties without expanding or limiting existing HIPAA obligations. (Thus, the changes enhance fiduciary oversight of group health plan payments and claims processing.)

This section establishes new ERISA requirements, effective for plan years beginning two years after enactment, prohibiting agreements between group health plans (or their sponsors, administrators, business associates, or group health insurers) and health plan service providers—defined to include health care providers, networks, third-party administrators, pharmacy benefit managers, and other third parties—from limiting or delaying disclosure of specified information and requiring quarterly disclosures of that information at no cost to plans or issuers, subject to HIPAA privacy rules. Disclosures must include (1) information on service provider claims payment practices; (2) detailed contractual and subcontractual reimbursement methodologies, fee schedules, and adjustments; (3) total amounts received or expected in rebates, fees, discounts, and other remuneration, including from data sales or escrow; (4) total amounts paid or expected to subcontractors for services; and (5) payment and reconciliation data for alternative arrangements (e.g., accountable care organizations, bundled payments, capitation). This section further amends ERISA's civil enforcement provision (29 U.S.C. 1132(a)(6)) to authorize the Secretary of Labor to collect civil penalties under new paragraphs (13) and (14) of subsection (c) for violations. (Thus, plans gain enhanced ability to verify service provider compliance, fees, and rebates.)

This section limits the preemption of state laws establishing requirements or prohibitions related to health care price transparency—including for hospitals, clinical diagnostic laboratory tests, imaging services, and ambulatory surgical centers—by the requirements of sections 2 through 5 (and their amendments), except to the extent of any direct conflict. This section does not affect group health plans under the Employee Retirement Income Security Act of 1974 (ERISA) or alter the application of ERISA's preemption provision (29 U.S.C. 1144).

This section amends the Public Health Service Act (PHSA), Internal Revenue Code (IRC), and Employee Retirement Income Security Act of 1974 (ERISA)—which implement federal surprise medical billing protections for group health plans and health insurance coverage—to (1) revise advanced explanation of benefits requirements for emergency services by specifying that good faith estimates include plain language descriptions of each item or service and all applicable billing codes (including modifiers) using standard sets and (2) require, for plan years beginning on or after January 1, 2026, an explanation of benefits notification within 45 days of receiving any payment request that discloses provider or facility participation status; itemized plain language descriptions and billing codes (including modifiers) for each item or service; plan payment amounts; enrollee cost-sharing; progress toward deductibles and out-of-pocket limits; and site of service. These notifications must use clear language and substantially the same format as the advanced explanation of benefits to enable comparison and, if applicable, may accompany claim determinations. The Secretaries must implement these requirements through notice-and-comment rulemaking.

This section establishes requirements under the Public Health Service Act for health care providers and facilities to furnish individuals with a written itemized bill—not later than 30 days after receiving final third-party payment—when requesting payment for provided items or services (including telehealth). The bill must detail (1) a plain language description of each item or service; (2) applicable billing codes and modifiers; (3) price and billed amount (or binding bundled price); (4) payments received on the individual's behalf; (5) language-assistance services information; (6) a contact for discussing and correcting the bill; and (7) charity care policies and application instructions. This section further prohibits collection actions against individuals unless the provider or facility complies and, for amounts exceeding good faith estimates or federal price transparency disclosures (e.g., 45 C.F.R. pt. 180), unless the provider documents medically necessary unforeseen complications (with burden of proof on the provider, rendering the estimate binding otherwise). The Secretary must impose civil penalties of up to $10,000 per violation and presume charges exceed good faith estimates in patient-provider disputes if requirements are unmet; implementation occurs via notice-and-comment rulemaking.