Patients Deserve Price Tags Act

Bill Number: H.R. 5582
Origin Chamber: House
Congress: 119th Congress, Session 1
Policy Area: Health
Status: Introduced
Latest Action: 2025-09-26: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Last Updated: 2026-06-11T05:06:23Z

AI-Generated Summary

Purpose

The "Patients Deserve Price Tags Act" (H.R. 5582) seeks to promote transparency in healthcare pricing by requiring hospitals, laboratories, imaging providers, ambulatory surgical centers (ASCs), health insurers, and group health plans to publicly disclose detailed pricing information. This aims to empower patients to compare costs, reduce surprise billing, and encourage competition to lower prices, building on existing federal rules while expanding coverage to more providers and services.

Key Provisions

Hospital Price Transparency (Section 2): Hospitals must monthly publish all standard charges for items and services provided (in inpatient and outpatient settings) in a machine-readable format, free of charge and without subscription. This includes:
Plain-language descriptions with billing codes (e.g., CPT, HCPCS).
Gross charge (full list price from the hospital's "chargemaster").
Discounted cash price (lowest price for self-pay patients, accepted as full payment regardless of insurance; if unavailable, the minimum cash price over the past three years, plus a link to charity care policy).
Payer-specific negotiated charges (contracted rates with each insurer and plan, including formulas or algorithms used to calculate them).
De-identified maximum and minimum negotiated charges.
By December 31, 2026, at least 300 "shoppable services" (pre-schedulable services like MRIs) must be listed in a consumer-friendly format; after that, all shoppable services.
The Secretary of Health and Human Services (HHS) must establish uniform formats by January 1, 2026, ensuring accessibility.
Price estimator tools do not count toward compliance.
Annual compliance monitoring, senior official attestation (material to federal payments), and enforcement: Initial notification and corrective action plan required; penalties start after 45 days of noncompliance, scaled by hospital bed size (e.g., $300/day for small hospitals, up to $35 per bed per day for large ones, with increases for persistent or willful violations up to $10 million). No waivers allowed. Technical assistance available.
Effective January 1, 2026; does not affect prior rules.

Clinical Diagnostic Laboratory Price Transparency (Section 3): Applicable laboratories (independent labs, excluding those covered by hospital disclosures) must, starting July 1, 2027, monthly update and post on their websites pricing for "specified" lab tests (shoppable tests not exclusive to one provider). Includes similar details as hospitals (gross charge, discounted cash price, payer-specific negotiated charges, min/max negotiated), plus ancillary services (e.g., specimen collection). Uniform machine-readable format by January 1, 2027. Enforcement: Notification after 30 days, penalties up to $300 per day after 90 days (increasable via rulemaking). Technical assistance provided.

Imaging Services Price Transparency (Section 4): Providers or suppliers of specified imaging services (shoppable imaging like X-rays, excluding hospital-covered ones) must, starting July 1, 2027, annually post pricing on websites, with similar details. Uniform format by January 1, 2027. Annual compliance monitoring. Enforcement: Notification, corrective action plan after 45 days, penalties up to $300 per day after 90 days (increasable). No waivers; this is the sole enforcement mechanism. Technical assistance available.

Ambulatory Surgical Center Price Transparency (Section 5): ASCs with hospital ownership or control must, starting July 1, 2027, annually publish standard charges for all items/services and prices for at least 300 shoppable services in machine-readable and consumer-friendly formats, with similar details. Uniform formats by January 1, 2027. Price estimators do not count. Annual monitoring. Enforcement: Notification, corrective action after 45 days, penalties up to $300 per day after 90 days (increasable). No waivers; technical assistance provided.

Health Coverage Transparency (Section 6): Amends the Affordable Care Act (ACA) to enhance insurer and plan disclosures:
Exchanges and plans must provide real-time self-service tools (internet-based, updated timely) for cost estimates, including in-network rates, out-of-network maximum allowed amounts, cost-sharing (deductibles, copays, coinsurance), accumulated deductibles/out-of-pocket maximums, usage toward limits, and prior authorization requirements. Requests can use billing codes or descriptions; paper/phone options available at no cost. Plans hold users harmless if tool estimates differ from final bills.
Starting January 1, 2027, monthly public submission of machine-readable files to Exchanges, HHS, state commissioners, and the public on: in-network rates by provider (with NPI identifiers, excluding inactive ones); drug net prices (historical, net of rebates) and in-network rates; out-of-network billed/allowed amounts. Files must include descriptions, codes, formulas for calculations, and attestations by executives (material to federal payments). User guides required. Applies to Medicare ACOs.
Annual audits (at least 20 plans); enforcement: Notification, corrective action after 30 days, penalties up to $300 per member per day or $10 million after 90 days.
Effective January 1, 2026; preserves prior Transparency in Coverage rule.

Group Health Plan Access to Health Data (Section 7): Amends ERISA to prohibit contracts with providers, third-party administrators (TPAs), or pharmacy benefit managers (PBMs) that restrict plan fiduciaries' access to claims data, medical records, or pricing (e.g., no gag clauses limiting audits, daily batch access, or disclosure of value-based payments, overpayments, or fees). Data must follow HIPAA standards (e.g., X12N 837/835 formats). Annual attestations required; if data unavailable, explain efforts to obtain it. Voids restrictive provisions. Civil penalties up to $10,000 per day. Effective one year after enactment.

Oversight of Administrative Service Providers (Section 8): Adds ERISA and Public Health Service Act (PHSA) provisions prohibiting agreements that limit quarterly disclosures by TPAs, PBMs, etc., to plans/issuers on: claims data; reimbursement formulas; rebates/fees (received/paid); alternative payment data (e.g., bundled payments). Must comply with HIPAA privacy/security. Prohibits delaying access beyond quarterly. Voids restrictive clauses. Penalties $100,000 per day. Effective 1-2 years after enactment, with enforcement within 90 days of violations.

State Preemption (Section 9): Federal rules do not override state transparency laws unless states directly conflict; no impact on ERISA preemption for group plans.

Explanation of Benefits (Section 10): Amends PHSA, Internal Revenue Code, and ERISA to require plans/issuers, starting January 1, 2026, to send detailed explanations within 45 days of a claim, including: provider participation status; itemized services with descriptions/codes; plan payment amounts; patient cost-sharing; progress toward deductibles/out-of-pocket limits; service sites. Matches advanced EOB format; can combine with claim notices.

Provision of Itemized Bills (Section 11): Adds PHSA requirement for providers/facilities to send itemized bills within 30 days of final third-party payment, including: descriptions/codes; prices/billed amounts (or bundled totals); payments received; language assistance info; contact for questions; charity care details. No collection actions without compliance or if bills exceed good faith estimates/transparency disclosures (unless documented as unforeseen/necessary). Penalties up to $10,000 per violation; presumption of excess charges in disputes.

All sections require HHS (and DOL/Treasury for ERISA/ACA) implementation via notice-and-comment rulemaking.

Significant Changes to Existing Law

Expands 2019 hospital transparency rules (45 CFR Part 180) to mandate all charges (not just 300 shoppable), payer-specific details with formulas, monthly updates, and stricter enforcement (e.g., no estimator exemptions, scaled/no-waiver penalties).
Introduces new transparency for labs, imaging, and hospital-affiliated ASCs, absent from prior law.
Builds on 2020 Transparency in Coverage rule by requiring monthly machine-readable files with provider-specific rates/drug nets, real-time tools, and ACO inclusion; adds audits and per-member penalties.
Strengthens ERISA/PHSA by banning gag clauses, mandating quarterly data access with HIPAA-compliant formats, and voiding restrictive contracts—addressing prior loopholes in plan oversight.
Enhances advanced EOBs and adds post-service EOBs/itemized bills with mandatory codes/details, going beyond current claim notice requirements.
Preserves but does not alter prior rules' applicability before effective dates.

Potential Impacts

Government Agencies: HHS, DOL, and Treasury face increased rulemaking, auditing (e.g., 20+ plans annually), monitoring, and enforcement duties, potentially raising administrative costs but improving data for policy (e.g., Medicare pricing). Penalties could generate revenue for compliance efforts.
Citizens/Patients: Greater ability to shop/compare prices, access discounted cash rates, and avoid surprises; itemized bills/EOBs aid disputes. May reduce out-of-pocket costs via competition and charity care visibility, though initial complexity could challenge low-income or non-English speakers (mitigated by language assistance).
International Relations: No direct impact; focuses on domestic U.S. healthcare.

Main Stakeholders Affected

Hospitals, Labs, Imaging Providers, ASCs: Bear primary disclosure burdens; hospital-affiliated entities face overlapping rules. Noncompliance risks significant penalties, potentially straining small/rural facilities.
Health Insurers, Group Health Plans, TPAs, PBMs: Must build/enhance tools, submit files, share data quarterly, and attest compliance; audits and penalties could increase operational costs but enable better negotiations.
Patients and Consumers: Primary beneficiaries through accessible pricing; self-pay and uninsured gain from cash price mandates and charity links.
Employers/Plan Sponsors: Improved oversight of plans via data access, aiding cost control.
States: Can maintain/enforce their laws unless conflicting, preserving flexibility.

Notable Legal, Constitutional, or Political Implications

Legal: Relies on existing PHSA/ACA/ERISA authority for transparency; integrates HIPAA privacy (no new burdens) and rulemaking processes. Enforcement via civil penalties (modeled on Social Security Act Section 1128A) ensures due process (notifications, corrective plans). State savings clause avoids federalism challenges; voids only conflicting gag clauses as against public policy.
Constitutional: Supports Commerce Clause regulation of interstate healthcare markets. No First Amendment issues, as disclosures are neutral factual requirements (not compelled speech beyond business norms). Equal protection upheld via scaled penalties for equity.
Political: Advances bipartisan goals of lowering costs (e.g., surprise billing reforms) without new entitlements; may reduce healthcare spending long-term via competition. Industry (hospitals/insurers) could resist due to data-sharing costs/competitive risks, but consumer focus likely aids passage. Aligns with post-COVID emphasis on accessible care.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. James, John [R-MI-10]

Cosponsors (11)

Rep. Goodlander, Maggie [D-NH-2], Rep. Kiggans, Jennifer A. [R-VA-2], Rep. Davis, Donald G. [D-NC-1], Rep. Owens, Burgess [R-UT-4], Rep. Vindman, Eugene Simon [D-VA-7], Rep. Calvert, Ken [R-CA-41], Rep. Vasquez, Gabe [D-NM-2], Rep. Fulcher, Russ [R-ID-1], Rep. Weber, Randy K. Sr. [R-TX-14], Rep. Spartz, Victoria [R-IN-5], Rep. Fields, Cleo [D-LA-6]

Recent Actions

2025-09-26: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
2025-09-26: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
2025-09-26: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
2025-09-26: Introduced in House
2025-09-26: Introduced in House

Bill Versions

Patients Deserve Price Tags Act — issued 2025-09-26 — PDF (100 pages)