Health Care Price Certainty for All Americans Act
- Sponsor
- Rep. Smith, Jason [R-MO-8]
- Committees
- Education and Workforce Committee (primary)
- Last action
- Jul 15, 2026
Bottom line
This bill aims to empower consumers and regulators with more comprehensive and accessible healthcare price and cost-sharing information across various sectors, while also increasing scrutiny on vertical integration in Medicare.
What it actually does
The bill significantly expands healthcare price transparency requirements for hospitals, clinical diagnostic laboratories, imaging services, and ambulatory surgical centers under Medicare. It also mandates new cost-sharing and rate/payment transparency for group health plans and health insurance issuers, phases out existing price comparison tool requirements, and prohibits pharmacy gag clauses. Furthermore, it introduces new reporting requirements for Medicare Advantage organizations and Prescription Drug Plan sponsors regarding vertical integration and provides funding for implementation.
Proponents argue
Supporters argue that increased price transparency will empower consumers to make informed healthcare decisions, foster competition among providers and insurers, and ultimately drive down healthcare costs. They contend that knowing prices upfront will reduce surprise billing and allow individuals to shop for services, leading to a more efficient and equitable healthcare market.
Opponents contend
Critics might argue that the extensive reporting requirements impose significant administrative burdens and costs on healthcare providers, laboratories, and insurers, which could be passed on to consumers or lead to reduced services. They may also contend that raw price data is not easily interpretable by consumers and could lead to confusion or unintended consequences without sufficient context on quality and outcomes.
The bill is quite long and detailed, requiring a significant time investment to fully understand its implications. The complexity of the legal amendments and technical definitions means that the time required for a thorough review is substantial.
Sec. 2(a) of the bill, amending Part E of title XVIII of the Social Security Act by adding new section 1899D(a).
Enhanced Hospital Price Transparency Requirements
Starting January 1, 2027, hospitals must publicly disclose all standard charges for items and services, including gross charges, payer-specific negotiated charges (max/min deidentified), and discounted cash prices. They must also provide prices for at least 300 'shoppable services' in a consumer-friendly format and maintain a price estimator tool. Hospitals must attest annually to the accuracy of this information.
Supporters argue
Supporters argue this provision will empower patients to shop for care, reduce surprise bills, and foster a more competitive healthcare market by making actual prices transparent, not just chargemaster rates.
Critics contend
Hospitals may contend that the administrative burden and cost of compiling and maintaining such detailed, real-time pricing information is substantial, especially for smaller or rural hospitals, potentially diverting resources from patient care. They might also argue that prices alone don't reflect value or quality.
Tradeoffs
Balances the desire for consumer empowerment and market competition through transparency against the administrative burden on hospitals and the complexity of healthcare pricing structures.
Sec. 2(b) of the bill, adding new section 1899D(b) to the Social Security Act.
Clinical Diagnostic Laboratory Price Transparency
Beginning January 1, 2028, applicable clinical diagnostic laboratories must publicly disclose discounted cash prices (or gross charges if no discounted price) for specified shoppable tests. This information must be updated annually, attested to by a senior official, and posted in a publicly accessible location. It also includes prices for ancillary services.
Sec. 2(c) of the bill, adding new section 1899D(c) to the Social Security Act.
Imaging Services Price Transparency
Starting January 1, 2028, providers and suppliers of specified imaging services (unless already covered by hospital or ASC transparency) must publicly disclose discounted cash prices (or gross charges) for these services. This information must be updated annually, attested to, and posted publicly.
Sec. 2(d) of the bill, adding new section 1899D(d) to the Social Security Act.
Ambulatory Surgical Center (ASC) Price Transparency
From January 1, 2028, ASCs must publicly disclose all standard charges for items and services, including gross charges, payer-specific negotiated charges (max/min deidentified), and discounted cash prices. They must also provide prices for at least 300 'shoppable services' and maintain a price estimator tool, similar to hospitals. Annual attestation of accuracy is required.
Sec. 3(a) of the bill, amending IRC section 9819, PHSA section 2799A-4, and ERISA section 719.
Mandated Cost-Sharing Information for Health Plans
Starting January 1, 2029, group health plans and health insurance issuers must provide participants/beneficiaries, upon request, with information on their out-of-pocket cost-sharing for specific items or services. This includes deductibles, copayments, coinsurance, in-network rates, maximum allowed amounts for out-of-network providers, accumulated amounts towards deductibles/out-of-pocket maximums, frequency limitations, prior authorization requirements, and financial incentives. This information must be available via a real-time self-service online tool or other requested formats.
Sec. 3(a) of the bill, amending IRC section 9819, PHSA section 2799A-4, and ERISA section 719.
Public Disclosure of Health Plan Rates and Payments
Starting January 1, 2029, group health plans and health insurance issuers (excluding grandfathered and church plans) must publicly disclose machine-readable files containing in-network rates for items/services (excluding drugs), in-network rates and average payments for drugs (accounting for rebates/discounts), and billed/allowed amounts for out-of-network services. This information must be updated quarterly, accompanied by user instructions, and a yearly summary data file.
Sec. 4 of the bill, adding new sections to PHSA, ERISA, and IRC.
Prohibition on Pharmacy Gag Clauses
This section prohibits group health plans and health insurance issuers, and their pharmacy benefit managers (PBMs), from restricting pharmacies from informing patients about cheaper drug options, including the differential between their out-of-pocket cost under insurance and the cash price. It also sunsets a previous related provision.
Sec. 5(a) of the bill, amending sections 1857(e) and 1860D-12(b) of the Social Security Act.
Medicare Advantage and Prescription Drug Plan Vertical Integration Reporting
For plan year 2028 and every third year thereafter, Medicare Advantage (MA) organizations with at least 25,000 enrollees and Prescription Drug Plan (PDP) sponsors must report to the Secretary specific information about their vertically integrated health care providers and pharmacies. This includes taxpayer IDs, incentive-based payments, and recoupments for both specified (affiliated) and non-specified providers/pharmacies.
Sec. 5(b) of the bill.
Medicare Payment Advisory Commission (MedPAC) Reports on Vertical Integration
MedPAC is mandated to submit two reports to Congress, starting approximately 2 years after the data from Sec. 5(a) becomes available. These reports will assess the state of vertical integration in the healthcare sector for entities participating in Medicare Parts C and D. They will evaluate MA organizations' risk scores and incentive payments, compare payments to affiliated vs. non-affiliated pharmacies/PBMs, summarize manufacturer-derived revenue retained by PBMs, and analyze the impact of integration on access, price, quality, and outcomes.
Sec. 6 of the bill.
Funding for Transparency Implementation
Appropriates $65,000,000 to the Secretaries of Health and Human Services and the Treasury, and $35,000,000 to the Secretary of Labor for fiscal year 2027, to remain available through FY 2032. These funds are for implementing the bill's provisions, including drafting regulations, issuing guidance, publishing reports, enforcement, data collection/analysis, and other administrative duties. Annual reports on expenditures are required.
Before the effective date of regulations for advanced explanations of benefits (No Surprises Act), hospitals are deemed compliant with shoppable services transparency if they maintain a specific price estimator tool.
Sec. 1899D(a)(2)(D) of the Social Security Act, as added by Sec. 2(a) of the bill.
Why it matters:Standard legislative practice to provide transitional rules or alternative compliance pathways during phased implementation of complex regulations.
Case for: Supporters would argue this provides flexibility for hospitals during a period of regulatory transition, allowing them to leverage existing or developing tools while awaiting final rules for broader interoperability.
Case against: Critics might argue that this 'deemed compliance' could create loopholes or delay full implementation of the more robust shoppable services requirements, potentially reducing the immediate impact of transparency.
Estimated impact: Potentially significant for hospitals in the interim period, affecting how quickly comprehensive shoppable service data becomes available.
The current requirement for group health plans to maintain a price comparison tool (under existing law) will sunset for plan years beginning on or after January 1, 2029. This is replaced by the new, more extensive cost-sharing and rate/payment transparency requirements.
Sec. 3(a)(1)(A)(iv) of the bill, amending IRC section 9819(a)(2). Similar amendments in PHSA and ERISA.
Why it matters:Standard legislative practice when replacing an older, less comprehensive requirement with a new, more robust one, ensuring a smooth transition.
Case for: Proponents would argue that the new transparency requirements are far more comprehensive and effective, rendering the older, less detailed price comparison tool obsolete and unnecessary, thus streamlining regulations.
Case against: Critics might argue that removing any existing transparency requirement, even if replaced, could create a gap or reduce accountability if the new system faces implementation delays or proves less effective in certain aspects.
Estimated impact: Shifts the regulatory landscape for health plan transparency, replacing one set of rules with a more demanding one.
MedPAC's report on vertical integration must evaluate the relationship between MA enrollees' risk scores, whether they received health risk assessments from affiliated providers, and incentive-based payments made to those affiliated providers.
Sec. 5(b)(2) of the bill, detailing the MedPAC report requirements.
Why it matters:This level of detail is typical for legislative directives to expert bodies, but the implications for potential upcoding or financial incentives are significant.
Case for: Supporters argue this is a critical component of oversight, ensuring that vertical integration does not create perverse incentives for MA organizations to inflate risk scores through affiliated providers, which can lead to higher federal payments.
Case against: Vertically integrated MA organizations might argue that health risk assessments by affiliated providers are part of legitimate care coordination and that scrutinizing risk scores in this way could be misinterpreted or discourage proactive health management.
Estimated impact: Could expose significant financial dynamics within the MA program, potentially leading to future policy changes regarding risk adjustment and provider incentives.