AHA Comments on Senate HELP's Patients Deserve Price Tags Act

July 2, 2026

Dear Chairman Cassidy and Ranking Member Sanders:

On behalf of our nearly 5,000 member hospitals, health systems and other healthcare organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 healthcare leaders who belong to our professional membership groups, the American Hospital Association (AHA) writes to share our review of the discussion draft of the Patients Deserve Price Tags Act (PDPTA) (S. 2355) released on June 25.

We appreciate the committee’s continued interest in improving the availability of pricing information for patients, policymakers, employers and other purchasers of healthcare services. While we recognize the substantial work done by committee staff and the bill’s sponsors to accommodate stakeholder feedback to S. 2355 — the PDPTA as introduced — we remain concerned that the updated draft language does not sufficiently advance the goals of healthcare price transparency. We welcome the opportunity to continue to provide input to the committee; however, the AHA opposes this discussion draft in its current form. Our recommendations for improving the bill are outlined below and are intended to help address our concerns, reduce operational challenges, and move the discussion draft toward a more workable approach.

General Comments

From a legal and drafting perspective, we continue to have significant concerns about the structure of the discussion draft. We are concerned about the discussion draft’s underlying drafting ambiguities and whether this bill could be operationalized as currently written. Given these drafting issues, it is possible that the agencies would interpret and implement the legislation in ways that Congress had not intended.

We also are concerned about the steep financial penalties for hospital noncompliance in the discussion draft. We question whether these penalties advance the goal of price transparency, which is to provide information to help guide patients in their course of care. While we understand the importance the committee is placing on ensuring patient and employer access to healthcare data, the discussion draft is structured to disproportionately penalize hospitals for any violation, including highly technical formatting infractions, in an additive fashion (that is, penalties on top of penalties), with little enforcement flexibility given to the agencies that are required to assess compliance. We question the need for these changes given the substantial level of enforcement activity in hospital price transparency compliance, with almost all hospitals adhering following a noncompliance concern raised by the Centers for Medicare & Medicaid Services (CMS). Of the over 7,500 enforcement reviews that CMS has opened to date, less than 0.01% have resulted in civil monetary penalties (CMPs). These data suggest that CMS’ current enforcement process is already resulting in hospitals correcting compliance concerns, and we encourage you to reconsider if additional statutory enforcement mechanisms are necessary. On the other hand, it is unclear if any audit or enforcement actions have been taken related to the Transparency in Coverage regulations, and no information is available on whether health plans are complying with those requirements. 

At a time when Congress is seeking to address waste in the healthcare system to promote greater affordability, it should be noted that there will be a significant administrative burden placed on hospitals and health systems to comply with myriad new reporting requirements envisioned in the discussion draft. The requirements will be both difficult to execute and costly to maintain. These additional burdens could be especially onerous for small and rural hospitals, some of which are already struggling to serve their communities with current staff and resources. Small hospitals have already borne the brunt of CMS’ enforcement actions. Of the 10 hospitals that received CMP notices from CMS in 2025, 70% were hospitals with bed counts of less than 50, and 40% were hospitals with a bed count of less than 30. 

As the committee considers changes to price transparency requirements, we encourage legislators to consider ongoing CMS updates to the Hospital Price Transparency Rule, including improvements already made for standardization, data elements, file access, accuracy affirmation and enforcement. We also would encourage the committee to consider whether the goals of price transparency could be furthered by having the health plans — which have myriad data on negotiated rates — as the more appropriate stakeholder to post some of the requested information. Passing legislation that conflicts with or adds to current requirements could undermine CMS’ efforts to update the existing requirements. We strongly suggest that the committee avoid creating duplicative, inconsistent or operationally impossible conditions that undermine existing transparency efforts.

Some of the most concerning issues we identified in the discussion draft are:

• Additional reporting burdens that will add administrative costs to hospitals, but do not consider current requirements for price transparency or improve patient access to data.
• Excessive and compounding enforcement mechanisms directed toward hospitals.
• Unequal treatment between providers and plans.
• Potentially bringing hospitals under the Employee Retirement Income Security Act (ERISA) authority.
• Holding providers responsible for pre-service estimates.

The following are comments specific to sections of the discussion draft.

Section 2: Strengthening Hospital Price Transparency

This section of the discussion draft would make significant changes to the existing hospital price transparency requirements, including changes to machine-readable files (MRF), shoppable services, provider definitions, enforcement, ownership information and facility fees. While we continue to appreciate your efforts to improve access to meaningful price information, we remain concerned that this section would be difficult to operationalize, could duplicate or conflict with existing CMS requirements and may reduce access to consumer-friendly tools.  

This section combines definitions for hospitals, labs, imaging centers and ambulatory surgical centers (ASCs) into a single provision, which may create confusion and unintended consequences. For example, there is a missing definition for an imaging service provider. Can a hospital be considered an imaging service provider?

Several other definitions would benefit from clarification. The “shoppable service” definition states: “The term ‘shoppable service’ means a service that can be scheduled by a healthcare consumer in advance. Such services are routinely provided in non-urgent situations that do not require immediate action or attention to the patient, thus allowing patients to price shop and schedule a service at a time that is convenient for them.”

The second sentence above is not in statutory legislative language that attaches this sentence to the definition of a “shoppable service” in the first sentence. So, is something only considered a shoppable service when it is a service for which a patient can schedule at any time they want? What if the time and date they want are not available? Is it no longer considered a “shoppable service?”

Similarly, the definition of an ASC needs additional clarity. While we appreciate the discussion draft no longer limits price transparency requirements to only those ASCs that are affiliated with a hospital, the new definition of a “specified ambulatory surgical center” is as “a distinct entity” — without a meaning to that term — and does not refer to the Medicare concept of an ASC. The revised definition requires the “distinct entity” to operate exclusively for providing surgical services to patients who do not require hospitalization. It is unclear, however, as to what constitutes surgical services or what is considered outside of surgical services, and what is considered “hospitalization,” and at what point the need for determining hospitalization is left open, although the expected duration of services could not exceed 24 hours. 

We also would note that there are references in the definitions to subsections that do not exist in the current draft of the bill, making the legislative intent uncertain.

Most importantly, this discussion draft appears to eliminate hospitals’ ability to use price estimator tools to satisfy the shoppable service requirement. We would appreciate clarification as to whether the new draft intends for CMS to offer a shoppable service standard format that is a price estimator tool, or would hospitals be expected to provide a consumer-friendly spreadsheet to meet the shoppable service requirements? Eliminating hospitals’ ability to comply with these requirements using their price transparency tool would both reduce access to a frequently used consumer-friendly research tool and unfairly penalize hospitals that have spent significant capital investing in these tools to comply with the regulation.

AHA’s 2024 focus group conducted with NORC found patients preferred hospitals’ web-based cost estimator tools compared to shoppable services spreadsheets, which participants found confusing and difficult to navigate. In addition, participants felt that price estimator tools more effectively provided the information they sought. Other studies have demonstrated that price estimator tools are useful for patients, for example, Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network - PMC and Examining A Health Care Price Transparency Tool: Who Uses It, And How They Shop For Care. These studies’ findings suggest that a cost estimation tool can be easy to use and provide accurate, real-time estimates for patients.

It appears that the discussion draft would require hospitals to develop and maintain a shoppable services spreadsheet instead of using price estimator tools. These spreadsheets may be difficult for consumers to navigate and will not reflect the different policies that their insurer may apply to determine the final price for a service. By contrast to spreadsheets filled with contracting details, price estimator tools can offer consumers a personalized estimate of their out-of-pocket costs based on their insurance benefit design, such as cost-sharing requirements and prior authorization, as well as the patient’s annual deductible. Eliminating the use of price estimator tools would therefore reduce price transparency for patients. We urge the committee to preserve hospitals’ ability to use compliant price estimator tools.

The discussion draft also requires hospitals to update their MRF monthly — if there are any changes to the standard charges — and incorporate all shoppable services into their shoppable service files. Currently, hospitals are required to update the MRF annually. It takes hospitals 3-4 months to update their files based on current requirements. While the discussion draft seems to offer flexibility that the files would not have to be updated “if there have been any changes to the standard charges described in subparagraph (2)” that month, we continue to stress that this statutory change does not address our concerns that this requirement would be highly burdensome and would require significant staff time and resources. Given constant minor updates related to hospital charges and negotiated rates, this would require hospitals to update their files almost every month. However, since most updates do not significantly change the value of the standard charges, we encourage the committee to further revise this draft to only require updates when there have been “material changes to the standard charges.” We recommend that the MRFs be required to be updated no more often than quarterly, and only if there are material changes to the charges. Even with this modification, we anticipate that this requirement would be especially burdensome for small, rural hospitals to maintain. Similarly, increasing the shoppable service requirement to include all shoppable services (up from “at least 300”) in a consumer-friendly spreadsheet would be untenable for most hospitals and of limited use to patients. 

The discussion draft also asks for “plain language” to be applied to MRF. However, MRF are meant to be read by machines, not by patients looking for information on the cost of their care. We agree that patients need to have access to hospital pricing information in plain language, and this is one major distinction between the consumer-friendly display and the MRF. This distinction is one reason hospitals should continue to be allowed to use consumer-facing estimator tools, which can present pricing information in a plain language format.   

The discussion draft has revised language on the “discounted cash price.” We appreciate that the committee sought to clarify language in the discussion draft to address posting a discounted cash price that excludes the application of financial assistance by hospitals. However, by linking this section to the definition of a provider, the language seems to also include labs, imaging centers and ASCs as providers. By including providers other than hospitals in this provision, the language is not as clear or protective for hospitals. We recommend breaking out the definition to clearly apply with respect to each provider to better preserve the definition and exemption for hospitals, rather than introducing ambiguities with the inclusion of other providers. In addition, the phrase “health insurance coverage” used in the definition is a defined term under section 2791 of the Public Health Service Act (PHSA). This definition does not include coverage offered by group health plans (ERISA plans) or, for example, coverage under Medicare or Medicaid, which may not be what was intended by the drafters.

The discussion draft adds duplicative reporting requirements. The draft language requires making the following information publicly available on a website: the name and business address for each person or entity that, with respect to the hospital, has an ownership or investment interest; has a controlling interest; is a management services organization; or is a significant equity investor. However, hospitals are already required to share ownership information at the federal level. This requirement should be reviewed for its interaction with (differences from, expansion of, and how it overlaps with) requirements of section 1124 of the Social Security Act and section 6101(b) of the Patient Protection and Affordable Care Act. In addition, CMS collects this information and makes it available to the public, which is more efficient than having each hospital post the information on individual websites. We recommend employing existing mechanisms rather than creating duplicative requirements to address any gaps in information.

Hospitals also would be required to post the amount of any facility fee or other patient charges that would be added to a patient’s bill, in addition to any information that might help the patient avoid the facility fee charge. Hospitals already include institutional fees, also known as facility fees, in their MRF. While the term “facility fee” is often used to describe these institutional fees, the charges are generally referred to by their standard description in the MRF. These fees also are typically included in hospitals’ price estimator tools. Also, per the requirement to help the patient avoid a facility fee charge, what does this mean in practice? Would this require a hospital to suggest a patient go to another care setting to receive their service? How would the hospital know if the other care setting applies a facility fee? 

The discussion draft adds additional enforcement actions for noncompliance. We appreciate that the discussion draft extends the time for hospitals to come into compliance with a corrective action plan (CAP) to 90 days (instead of 45 days in the bill as introduced) and that the Health and Human Services Secretary now has the flexibility to mitigate the imposition of CMPs if it is determined the penalty “will disrupt hospital operations in a manner that impacts patient care” (the bill as introduced removed any discretion by CMS to not apply a CMP: any price transparency violation made by a hospital would have required a CMP to be applied). 

However, the draft allows increased penalties even when a hospital was not “knowingly or willfully” noncompliant. We recommend restoring intent-based language and providing CMS with greater discretion to accommodate extreme or unusual circumstances.

In addition, we are concerned that a hospital receiving a CMP for failure to address a CAP also would be disallowed from engaging in any extraordinary collections actions (ECA) while out of compliance. The AHA encourages hospitals through our Patient Billing Guidelines not to garnish wages, place liens on a primary residence, apply interest to the debt, make contributions to adverse credit reports or file lawsuits against patients. However, as drafted, this provision is overly broad and likely to result in unintended consequences. Some hospitals may need limited flexibility to address unpaid balances in appropriate circumstances to continue to serve their communities.

We recommend narrowing this language to avoid restricting appropriate hospital billing and collection activity. 

The discussion draft applies differential oversight to hospitals and health plans. It is important to recognize that CMS currently executes considerable oversight of hospital adherence to the Hospital Price Transparency Rule and has regularly reviewed compliance with the regulation and issued CMPs. CMS publicizes hospital-specific information on all compliance assessment and enforcement activities, which is updated regularly on its public website. 

We appreciate that the discussion draft requires the secretaries of the Departments of Health and Human Services, Labor and the Treasury to annually issue a report to Congress that includes findings, conclusions and enforcement actions taken based on audits of the MRF posted by the health plans.

Given that CMS regularly takes action to ensure hospitals are complying with the Hospital Price Transparency Rule, we would ask that additional penalties assessed to hospitals in the discussion draft be re-evaluated by the committee, as there seems to be less oversight and fewer penalties assessed on other providers and to the health plans, which are subject to the terms of the PDPTA. For example, the bill requires CMS to audit all hospitals annually, but only up to 50 health plans annually. There are no increases in penalty amounts for plans, at the discretion of the Secretary (as with hospitals); there are no prohibitions against waivers from fines by the Secretary except for limited circumstances (as with hospitals and other providers); and there are no fines for health plans that are deemed to be in persistent non-compliance (like for hospitals).

Section 6: Strengthening Health Coverage Transparency Requirements

We continue to have concerns about the inconsistent treatment of health plans and hospitals in the PDPTA. For example, health plans are allowed to use “a self-service tool,” which must be internet accessible and provide real-time responses for requests from health plan beneficiaries for their out-of-pocket costs estimates, based on the provider they would like to use and the procedure they are seeking. This sounds very much like the price estimator tools that hospitals have expended much time and resources to put in place to meet the shoppable service requirement, which, for hospitals, will no longer be deemed compliant to meet the consumer-friendly requirement under the PDPTA discussion draft.

Section 7 and 8: Health Plan Access to Data; Administrative Service Provider Oversight

Both of these sections use broad terms that could include hospitals resulting in undue burdens and penalties on hospitals. We request clarification that hospitals are not intended to be covered service providers or healthcare service providers for the purpose of these sections. 

Section 10: Requirement for Explanation of Benefits

The discussion draft is inconsistent with statutory provisions in the No Surprises Act (NSA) (P.L. 116-260), which already addresses the implementation of advanced explanations of benefits (AEOBs). The legislation cites that “a participant, beneficiary, or enrollee shall be held harmless for any amount that is substantially in excess of the estimate generated by the advanced explanation of benefits (as defined by the Secretary) with respect to the benefits provided to such participant, beneficiary, or enrollee.” The AEOB estimate also is required to disclose the amount of any facility fee or other patient charges added to the final payment amount, together with a plain language explanation of the fee. It remains uncertain how the Secretary will define the AEOB. In addition, the provision states the individual is held harmless for an amount “substantially in excess” of the AEOB. Unless language is included in this section requiring the plan/issuer to make the provider whole, then the provider does not get paid the amount that is “substantially in excess” of the estimate, even if, as often occurs over the course of hospital care, issues arose that changed the final billed amount. While health plans are responsible for developing the pre-service estimate, providers may bear the financial consequences if the health plan estimate is inaccurate. 

To address this concern, the legislation should include an appeals process for the provider to be paid the difference, as there is for the uninsured/self-pay good faith estimates. In that case, should patients receive a bill greater than $400 more than their good faith estimate, they are not automatically held harmless but instead have access to a patient-provider dispute resolution process. Through this process, providers can justify why a final billed amount may be higher than the estimate, and depending on the result, the patient may still be required to pay the bill in full. This provision in the discussion draft is substantially less flexible and does not address the reality that often issues change over the course of care that render pre-service estimates inaccurate. 

Section 11: Provision of Itemized Bills

The itemized bill requirements of the discussion draft are unworkable. We recommend that the committee strike this section of the PDPTA. The technical standards for developing the AEOBs required by the NSA are still under development, and it will take time for those standards to be implemented and tested to ensure they agree with the final claims adjudications. Until that happens, we would recommend that final patient bills should not be linked to these estimates.

Our initial concern is that the 30-day timeline for the provider to send an itemized bill is unattainable if the payer has not sent the provider a final claims adjudication.

The discussion draft holds harmless insured patients for any billed amount higher than the AEOB estimate. But Section 11 states that providers cannot bill for the entire service — not the difference between the estimated amount and final adjudicated amount — unless there is documentation that additional services were provided as part of medical necessity. It is important to note that there is significant drafting confusion in this section, making it unclear whether the “price” and “good faith estimates” referenced are the NSA-required good faith estimates (which, in the case of insured individuals, would be the gross charge), the NSA-required AEOBs for insured patients, or a new type of estimate.

Based on our read, it appears the legislation intends to hold the provider fully accountable to the AEOB, uninsured/self-pay good faith estimate (GFE), and possibly “another good faith estimate provided by a healthcare entity covered under this section but not otherwise covered under such section 2799B-6”. What other types of estimates would be subject to this requirement? 

The proposed changes in this section of the discussion draft are quite different than the current law structure established by the NSA. For example, under current law sections 2799A-1(f) and 2799B-9 of the PHSA, if an individual relies on erroneous plan directory information to access an in-network provider who is actually out-of-network, the plan makes the individual whole by applying in-network cost-sharing, and the provider makes the individual whole by reimbursing any difference between what was charged and the amount that would be owed by the individual had the service been provided in-network.

As mentioned previously, the NSA also provides for a patient-provider dispute resolution process (see Section 2799B-7 of the PHSA) in the case of uninsured patients who receive the good faith estimate and actual charges are greater than $400 more than the estimate. Section 11 of the discussion draft does not acknowledge this process, so it is unclear how the existing statute would interact with the draft provisions. It’s also important to note that holding the provider fully accountable to the exact GFE (under this bill’s provision) is substantially different from the “in substantial excess” standard under section 2799B-7.

Importantly, it remains unknown whether providers will have access to AEOBs when those provisions of the NSA go into effect; if they do not have access to this information, providers will not know what pre-service estimate their patient received. 

Conclusion

Thank you again for your ongoing interest in improving the transparency of healthcare pricing information. We welcome the opportunity to provide additional feedback as the legislative process progresses. Please contact me directly, or have a member of your team contact Aimee Kuhlman, AHA group vice president of advocacy and grassroots, at akuhlman@aha.org or Jason Kleinman, director, federal relations, at jkleinman@aha.org.

Sincerely,

/s/

Lisa Kidder Hrobsky 
Senior Vice President
Federal Relations, Advocacy, and Political Affairs