Patients Deserve Price Tags Act
- Sponsor
- Rep. James, John [R-MI-10]
- Committees
- Ways and Means Committee (primary)
- Last action
- Sep 26, 2025
Bottom line
The bill aims to empower consumers and group health plans with unprecedented access to healthcare pricing and financial data, fostering competition and accountability through stringent disclosure mandates and significant penalties.
What it actually does
This bill significantly expands and strengthens price transparency requirements across the healthcare sector, mandating public disclosure of detailed pricing information from hospitals, clinical diagnostic laboratories, imaging services, and ambulatory surgical centers. It also requires health plans to provide real-time cost-sharing information to consumers and submit extensive machine-readable files of negotiated rates. Furthermore, the bill increases group health plans' access to claims and financial data from their service providers, prohibits gag clauses in contracts, and imposes substantial civil monetary penalties for non-compliance.
Proponents argue
Proponents argue that this bill is a crucial step towards making healthcare prices transparent, enabling consumers to make informed decisions, fostering competition among providers and insurers, and ultimately driving down healthcare costs. They contend that by exposing hidden fees and negotiated rates, the bill will hold all actors in the healthcare system accountable and protect patients from surprise billing.
Opponents contend
Opponents contend that the bill imposes an excessive administrative and financial burden on healthcare providers, health plans, and their service providers, which could lead to increased costs passed on to consumers. They also raise concerns that the mandated disclosure of proprietary negotiated rates and financial algorithms could undermine competitive negotiations, disrupt existing market dynamics, and potentially lead to unintended consequences like market consolidation or reduced innovation.
The bill is lengthy and technically dense, requiring significant time to fully grasp its implications, especially for non-specialists.
Section 2(a), amending PHS Act Section 2718(e)
Enhanced Hospital Price Transparency
This provision requires hospitals to compile and publicly disclose, on a monthly basis, all their standard charges for every item and service. This includes gross charges, discounted cash prices, payer-specific negotiated charges (with the name of the payer and plan), and de-identified maximum and minimum negotiated charges. Hospitals must provide this information in both a machine-readable spreadsheet and a consumer-friendly format for at least 300 shoppable services, expanding to all shoppable services by 2027. Senior hospital officials must attest to the accuracy of these disclosures, and significant civil monetary penalties, scaled by hospital size, are established for non-compliance, with no waivers permitted.
Supporters argue
Supporters argue that this provision is essential for true price transparency, empowering consumers to shop for healthcare services and driving competition among hospitals to lower costs. The attestation requirement and substantial penalties are seen as necessary to ensure robust compliance and prevent hospitals from circumventing the rules.
Critics contend
Critics contend that the detailed, monthly disclosure requirements impose an immense administrative and financial burden on hospitals, potentially leading to increased operational costs that could be passed on to patients. They also argue that disclosing proprietary negotiated rates could harm competitive negotiations and that the data may be too complex for average consumers to use effectively.
Tradeoffs
The provision balances the goal of comprehensive consumer access to pricing information with the significant administrative burden placed on hospitals and the potential impact on competitive market dynamics due to the disclosure of proprietary negotiated rates.
Section 3, adding PHS Act Section 2718(f)
Clinical Diagnostic Lab Price Transparency
This provision mandates that clinical diagnostic laboratories publicly disclose detailed pricing information for each specified clinical diagnostic laboratory test they furnish, starting July 1, 2027. The required information includes a plain language description, billing codes, gross charges, discounted cash prices, payer-specific negotiated charges (with payer and plan names), and de-identified maximum and minimum negotiated charges. This information must be updated monthly and include ancillary services. Civil monetary penalties of up to $300 per day can be imposed for non-compliance.
Section 4, adding PHS Act Section 2718(g)
Imaging Services Price Transparency
This provision requires providers and suppliers of specified imaging services (who are not already covered by hospital transparency rules) to publicly disclose detailed pricing information for each service they furnish, starting July 1, 2027. The required information includes a plain language description, billing codes, gross charges, discounted cash prices, payer-specific negotiated charges (with payer and plan names), and de-identified maximum and minimum negotiated charges. This information must be updated annually. Civil monetary penalties of up to $300 per day can be imposed for non-compliance, with no authority to waive or reduce penalties.
Section 5, adding PHS Act Section 2718(h)
Ambulatory Surgical Center Price Transparency
This provision requires specified ambulatory surgical centers (ASCs), defined as those with a hospital ownership or control interest, to publicly disclose their standard charges and prices for shoppable services, starting July 1, 2027. The required information includes a description of services, billing codes, gross charges, discounted cash prices, payer-specific negotiated charges (with payer and plan names), and de-identified maximum and minimum negotiated charges. This must be provided in both machine-readable and consumer-friendly formats, covering at least 300 shoppable services. Civil monetary penalties of up to $300 per day can be imposed for non-compliance, with no authority to waive or reduce penalties.
Section 6, amending PPACA Section 1311(e)(3)(C) and adding new subparagraphs
Enhanced Health Plan Transparency and Data Disclosure
This provision significantly strengthens health coverage transparency. It requires health plans to provide individuals with real-time, self-service tools (online, paper, or phone) to obtain personalized cost-sharing information for specific items and services, including in-network rates, maximum allowed amounts, deductible/out-of-pocket accumulation, and prior authorization requirements. Additionally, health plans must submit to regulators and make publicly available, on a monthly basis, three machine-readable files containing: 1) in-network rates for all items/services, including prescription drugs, with provider identifiers; 2) historical net drug prices (net of rebates/discounts); and 3) out-of-network allowed amounts. These files must include calculation formulae and pricing methodologies. An officer must attest to the accuracy of these disclosures, and civil monetary penalties of up to $300 per member per day or $10,000,000 can be imposed for non-compliance.
Section 7, amending ERISA Section 408(b)(2) and 502(c)
Group Health Plan Data Access and Gag Clause Prohibition
This provision amends ERISA to ensure that contracts between group health plans and their service providers (including health care providers, networks, TPAs, and PBMs) are deemed 'unreasonable' if they limit or delay the plan's access to claims and encounter information, payment documentation, pricing terms for value-based arrangements, overpayment recovery terms, or audit rights. It explicitly prohibits 'gag clauses' that restrict such data access and declares any such provisions void as against public policy. Violations by service providers are subject to a civil penalty of $10,000 per day. The bill also specifies data format standards for claims and payment information.
Section 8, adding ERISA Section 726 and PHSA Section 2799A-11
Enhanced Oversight and Disclosure for Health Plan Service Providers
This provision requires health plan service providers (including PBMs, TPAs, and networks) to quarterly provide group health plans (including self-funded non-Federal governmental plans) with extensive financial information. This includes contractual and subcontractual calculation methodologies, fee schedules, all remuneration received (e.g., rebates, fees, alternative discounts, amounts in escrow, data sales), and all amounts paid to subcontractors. It explicitly prohibits contractual provisions that limit or delay this disclosure, deeming them void. Any failure to comply results in a civil penalty of $100,000 per day. The Secretary is mandated to implement this through rulemaking.
Section 10, amending PHSA, IRC, and ERISA
Itemized Explanation of Benefits (EOB)
This provision requires group health plans and health insurance issuers to provide participants, beneficiaries, or enrollees with an itemized Explanation of Benefits (EOB) within 45 days of receiving any payment request for an item or service, starting January 1, 2026. The EOB must be in clear, understandable language and include whether the provider is participating, a plain language description of each service, all applicable billing codes, the amount the plan is responsible for paying, the individual's cost-sharing, the amount incurred towards deductibles and out-of-pocket maximums, and the site of service. The format should be similar to the advanced explanation of benefits required by existing law.
Section 11, adding PHS Act Section 2799B-10
Provider Requirement for Itemized Bills
This provision requires healthcare providers and facilities to provide individuals with a written, itemized bill within 30 days of receiving final payment from a third party. The bill must include a plain language description of each service, all applicable billing codes, the price and billed amount, any payments already made, language assistance information, a contact for billing questions, and charity care policies. Crucially, providers are prohibited from taking collections actions if the itemized bill was not provided, or if the charges exceed a good faith estimate (GFE) unless the provider documents unforeseen medical necessity or patient-initiated changes, with the burden of proof on the provider. If not documented, the GFE is binding. Penalties of up to $10,000 per instance of non-compliance can be imposed.
If payer-specific negotiated charges are based on an algorithm, percentage of another amount, or other formula or criteria, the hospital must disclose such algorithm, percentage, formula, or criteria as set forth in its contract and any other terms, schedules, exhibits, data, or other information referenced in any such contract as shall be required to determine and disclose the negotiated charge.
Section 2(a), amending PHS Act 2718(e)(1)(B)(iv)
Why it matters:While technical specifications are often detailed, requiring the disclosure of proprietary algorithms and formulas for negotiated rates is a significant policy shift that could be intentionally obscured within dense legislative text due to its contentious nature.
Case for: Proponents argue that without the disclosure of underlying algorithms and formulas, true price transparency is impossible, as many negotiated rates are not simple dollar amounts. This provision ensures that the full complexity of pricing is revealed, preventing obfuscation and enabling meaningful comparisons.
Case against: Opponents contend that this mandate forces the disclosure of highly sensitive proprietary business information, which could undermine competitive negotiations between hospitals and payers, potentially leading to market instability or reduced innovation in payment models.
Estimated impact: Could fundamentally alter how health plans and providers negotiate contracts and how their financial relationships are understood.
A senior official (CEO, CFO, or equivalent) from each hospital must attest to the accuracy and completeness of the price transparency disclosures, and this attestation shall be deemed 'material to payment from the Federal Government to the hospital.'
Section 2(a), amending PHS Act 2718(e)(4)
Why it matters:While attestation is a common accountability mechanism, the phrase 'material to payment from the Federal Government' significantly elevates the legal and financial stakes for non-compliance, making it more than a routine administrative task. This strong language could be intentionally placed to avoid drawing immediate attention.
Case for: Proponents argue that this provision ensures high-level accountability for the accuracy and completeness of price data, deterring hospitals from submitting incomplete or misleading information. Linking it to federal payments provides a powerful incentive for compliance.
Case against: Opponents may argue that placing such significant personal liability on senior executives for complex and voluminous data sets is overly punitive and could lead to overly cautious or delayed disclosures, or even discourage compliance due to fear of severe repercussions.
Estimated impact: Significantly increases the personal and institutional stakes for hospital compliance with price transparency rules.
Regulations promulgated under this section shall ensure that the rates, amounts, and prices to be disclosed by health plans include 'contractual terms containing calculation formulae, pricing methodologies, and other information necessary to determine the dollar value of reimbursement.'
Section 6(b), amending PPACA 1311(e)(3)(E)(iii)(II)(bb)
Why it matters:This is a highly significant requirement that forces the disclosure of proprietary business logic, similar to the hospital provision. Its placement within technical formatting rules could be an attempt to make it less conspicuous, given its contentious nature.
Case for: Supporters argue that without the underlying calculation formulae and pricing methodologies, the raw data on negotiated rates would be incomplete and difficult to interpret, limiting its utility for meaningful analysis and comparison. This ensures true transparency.
Case against: Critics, particularly health plans and insurers, will strongly argue that this mandates the disclosure of highly sensitive proprietary business information that is central to their competitive strategies. They contend it could undermine their ability to negotiate favorable rates and disrupt the market.
Estimated impact: Could fundamentally change how health plans operate and how their costs are understood, by revealing the mechanics of their reimbursement models.
Prohibits contracts between group health plans and Covered Service Providers from limiting the disclosure of pricing terms for value-based payment arrangements or capitated payment arrangements, including payment calculations, formulas, quality measures, contract terms, payment amounts, and measurement periods for all incentives.
Section 7(a)(1), amending ERISA 408(b)(2)(C)(ii)(III)
Why it matters:Value-based care models often involve complex, proprietary pricing structures. Mandating the disclosure of these terms is a significant step towards transparency in an area that has historically been opaque. Its placement could be to avoid immediate scrutiny as a standalone provision.
Case for: Proponents argue that this is essential for plan fiduciaries to understand the true costs and incentives within value-based care models, ensuring they are acting in the best interest of beneficiaries. It promotes accountability and allows for proper evaluation of these innovative payment structures.
Case against: Providers and payers involved in value-based care argue these terms are highly proprietary and disclosing them could undermine the competitive advantage of innovative models or lead to less willingness to engage in such arrangements.
Estimated impact: Could significantly alter the landscape of value-based care contracting and transparency, potentially impacting the adoption and structure of these models.
Requires health plan service providers to disclose to group health plans the total amount received or expected in provider/supplier rebates, fees, alternative discounts, and all other remuneration (including amounts held in escrow or variance accounts, data sales, or network payments), and the total amount paid to subcontractors for administrative and other services.
Section 8(a)(1), adding ERISA 726(b)(1)(C) and (D)
Why it matters:This is a critical provision for understanding the true financial flows in the healthcare supply chain, particularly for PBMs, which often derive significant revenue from rebates and other opaque arrangements. Its placement within a list of technical disclosures could be an attempt to downplay its revolutionary impact on business models.
Case for: Proponents argue that this is essential to address a major source of opacity in healthcare costs, allowing group health plans to identify hidden fees, understand the true cost of services, and ensure they are getting the best value for their beneficiaries. It promotes accountability for intermediaries.
Case against: Opponents, especially PBMs, will argue that this information is highly proprietary and competitively sensitive, and its disclosure could disrupt their business models, reduce their ability to negotiate favorable terms with pharmaceutical manufacturers, and ultimately lead to higher drug costs.
Estimated impact: Could expose significant revenue streams for PBMs and other intermediaries, leading to renegotiations, potentially lower costs for plans, and a fundamental shift in business practices.
Prohibits healthcare providers or facilities from taking collections actions against an individual for any items or services where the amount on an itemized bill exceeds the amount disclosed in a good faith estimate (GFE), unless the provider documents that additional items or services were medically necessary due to unforeseen complications or a patient-initiated change, and could not reasonably have been anticipated. The burden of proof rests with the provider, and absent such documentation, the GFE is binding.
Section 11(a)(2)(A)(ii), adding PHS Act 2799B-10(a)(2)(A)(ii)
Why it matters:This provision effectively makes good faith estimates binding in most cases, which is a substantial change from previous practices and significantly strengthens consumer protections against surprise bills. Its placement could be an attempt to make this significant shift less conspicuous.
Case for: Proponents argue that this provision provides robust protection for consumers against surprise medical bills, ensuring that patients are only charged what they were initially estimated, unless there are clear, documented, and unforeseen medical reasons. It holds providers accountable for their estimates.
Case against: Providers argue that medical care can be inherently unpredictable, and it is often difficult to provide a perfectly accurate estimate for all potential services. Making GFEs binding, even with exceptions, places an undue burden on providers and could lead to increased administrative costs or defensive medicine.
Estimated impact: Significantly strengthens consumer protections against surprise medical bills by making good faith estimates largely binding, shifting financial risk and burden of proof to providers.