Health Care PRICE Transparency Act
The Health Care PRICE Transparency Act would strengthen price transparency for both hospitals and insurers. For hospitals, it requires public posting of detailed standard charges in a consumer-friendly, machine-readable format, including descriptions of services, gross charges, payer-specific negotiated charges, de-identified min/max negotiated charges, discounted cash prices, and relevant billing codes. Hospitals must make these data available for at least 300 “shoppable” services (70 CMS-listed plus hospital-selected services) or as many as they provide if they don’t meet 300. If a hospital offers an internet price estimator tool that meets specified requirements (real-time cost estimates, no subscription, no personal information required, searchable by service or payer), CMS is to deem it compliant. The bill also adds penalties of up to $300 per day for noncompliance. In addition, the bill expands the ACA’s Transparency in Coverage provisions to require new disclosures: in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges, and negotiated rates plus historical net prices for prescription drugs. It requires an internet-based self-service tool with real-time cost-sharing estimates (and paper options on request) and sets standards for how information must be delivered, including protections for explanations and disclaimers about cost-sharing, coverage, deducibles, and potential balance billing. The act also extends these disclosure requirements to group health plans and health insurance coverage.
Key Points
- 1Hospitals must publish standard charges in plain language, free of charge, and in a machine-readable format, including:
- 2- Description of each item/service
- 3- Gross charge, payer-specific negotiated charge, de-identified min and max negotiated charges, and discounted cash price
- 4- Relevant billing/CPT/HCPCS/DRG/NDC codes
- 5Hospitals must publish for at least 300 shoppable services (70 CMS-specified plus hospital-selected), or as many as they provide; CMS may deem a hospital compliant if it operates an internet price estimator meeting specific criteria (real-time estimates, user-accessible, no subscription/PII, searchable by service and payer).
- 6Enforcement includes civil monetary penalties up to $300 per day for ongoing noncompliance, enforceable like other civil penalties under SSA 1128A.
- 7The bill expands ACA’s Transparency in Coverage requirements to include:
- 8- In-network provider rates for covered items/services
- 9- Out-of-network allowed amounts and billed charges
- 10- Negotiated rates and historical net prices for covered prescription drugs
- 11The standards require an internet-based self-service cost estimator tool and a paper option on request, with minimum features such as cost-sharing estimates, accumulated amounts, and a breakdown of in-network vs out-of-network pricing, plus required disclaimers.
- 12Definitions are established for key terms (e.g., shoppable service, standard charges, negotiated rate, de-identified charges, historical net price) to ensure clarity in reporting and calculations.
- 13The act applies to group health plans and health insurance coverage, in addition to qualified health plans.