Health Care Price Certainty Act

Full Title:
Health Care Price Certainty for All Americans Act

Summary#

This bill requires many health care providers, insurers, and plans to publish detailed prices and make cost estimates available to patients and the public.

Key provider requirements (effective dates):

  • Hospitals: starting January 1, 2027, specified hospitals must publish all standard charges and a set of prices for at least 300 “shoppable services,” post discounted cash prices (or median cash prices when no cash price exists), provide billing codes and plain-language descriptions, and submit an annual attestation of accuracy. The Secretary must set uniform formats (machine-readable for charge lists; consumer-friendly for prices) by January 1, 2028. Hospitals that offer an approved price estimator tool can meet some shoppable-services rules. The Secretary will monitor compliance, audit, publish enforcement actions, and may impose civil monetary penalties that vary by hospital size. Technical assistance, waivers, and hardship exemptions are allowed.
  • Clinical diagnostic laboratories: beginning January 1, 2028, applicable laboratories paid under Medicare must publish discounted cash prices (or gross charges if no cash price) for specified tests, update annually, submit attestation, include ancillary services in posted prices, and follow a uniform format set by the Secretary. The Secretary will monitor and enforce compliance with civil monetary penalties up to specified daily limits.
  • Imaging providers and suppliers: beginning January 1, 2028, providers paid under Medicare for specified imaging services must publish discounted cash prices (or gross charges), update annually, attest to accuracy, and follow a uniform format. The Secretary will set monitoring and civil penalty rules.
  • Ambulatory surgical centers: similar publication, attestation, price posting, uniform formats, monitoring, and penalties starting January 1, 2028.
  • Accessibility: the Secretary must require reasonable steps to make posted price information accessible to people with limited English proficiency and disabilities.

Health plan and insurer changes:

  • Existing rule that required a price comparison tool will remain in effect through plan years before 2029. For plan years starting on or after January 1, 2029, group health plans and issuers must provide cost-sharing estimates to participants, beneficiaries, or enrollees on request. These estimates must include in-network rates, maximum allowed amounts for out-of-network providers, estimated out-of-pocket cost (deductibles, copays, coinsurance), accumulated deductible and out-of-pocket amounts, prior authorization or utilization rules, and other items the Secretary requires. Plans must provide a self-service tool that gives real-time responses and is accessible.
  • Plans and issuers must also publish public rate-and-payment information starting for plan years on or after January 1, 2029. That information must be in separate machine-readable files, updated quarterly, and include in-network rates for items and services, drug payment averages (adjusted for rebates and discounts), amounts billed and allowed for out-of-network services, and summary data (mean, median, trends, and other details). Plans must post user instructions and an annual downloadable summary file.
  • Attestations: plans, issuers, and applicable providers must submit annual attestations signed by senior officials that the published information is true, accurate, and complete. Plans must take steps to ensure accessibility for people with limited English or disabilities.

Prescription drug information:

  • Group plans and issuers may not restrict a pharmacy from informing an enrollee if paying cash would cost the enrollee less than using coverage. PBMs contracted by plans may not restrict pharmacies from sharing this information. The bill defines out-of-pocket cost for this purpose.

Vertical integration and reporting:

  • Medicare Advantage (MA) organizations and Part D prescription drug plan sponsors must report ownership and financial information about related providers and pharmacies for plan year 2028 and every third year after. The Secretary will share that information with the Medicare Payment Advisory Commission (MedPAC).
  • MedPAC must report on vertical integration in Medicare, including effects on prices, access, and quality, and must analyze relationships between MA organizations and affiliated providers. Reports are scheduled about two and four years after the Secretary makes MA and PDP integration data available to MedPAC.

Reports and studies:

  • The Secretary must report on the use of standards-based APIs to make price data accessible by January 1, 2029, and annually thereafter.
  • The Secretary must study a provider tool for clinicians and report within one year of enactment.
  • The Comptroller General must report on compliance and enforcement by January 1, 2029, and the Departments must report biennially on differences in negotiated prices across markets.
  • The Secretaries must study feasibility of adding quality data linked to price transparency and report within one year.

Implementation funding and enforcement:

  • The bill appropriates $65,000,000 to HHS and Treasury and $35,000,000 to Labor for fiscal year 2027, available through fiscal year 2032, to support rulemaking, guidance, enforcement, reporting, data collection, and other administrative needs. The bill sets civil monetary penalties for noncompliance for hospitals, laboratories, imaging providers, ambulatory surgical centers, and plans as described in the text.

What it means for you#

  • If you get care at a hospital, lab, imaging center, or ambulatory surgical center, this bill would require those providers to publish prices and cash prices and to keep that information up to date.
  • If you have health insurance through a group plan or in the individual market, you could request an estimate of your out-of-pocket cost for a specific item or service and get a real-time response through a self-service tool starting in plan years beginning on or after January 1, 2029.
  • Pharmacies could tell you if paying cash is cheaper than using your insurance; the bill prevents plans and PBMs from blocking that communication.
  • Some of the price files will be machine-readable and may be available through APIs, which third-party apps could use if standards are developed.

Expenses#

  • The bill appropriates $65,000,000 to the Secretary of Health and Human Services and the Secretary of the Treasury for fiscal year 2027, to remain available through fiscal year 2032.
  • The bill appropriates $35,000,000 to the Secretary of Labor for fiscal year 2027, to remain available through fiscal year 2032.
  • The bill specifies civil monetary penalties for provider and laboratory noncompliance and describes limits and waiver or reduction authorities, but it does not specify how penalty revenues would be used.
  • No publicly available information on net federal budget effects, estimated administrative costs beyond the stated appropriations, or projected offsets is provided in the bill text.

Proponents' View#

No publicly available information.

Opponents' View#

No publicly available information.