HOPE and Mental Wellbeing Act of 2025
- Sponsor
- Rep. Salinas, Andrea [D-OR-6]
- Committees
- Ways and Means Committee (primary)
- Last action
- Feb 6, 2025
Bottom line
The bill aims to improve access to primary care, including mental health services, for Medicare and Medicaid beneficiaries by eliminating out-of-pocket costs for the first three visits each year.
What it actually does
This bill mandates that Medicare (Parts B and Advantage) and Medicaid programs cover the first three primary care visits annually without any cost sharing, such as deductibles, copayments, or coinsurance, for beneficiaries, starting in 2026. It broadly defines 'primary care visit' to include outpatient mental and behavioral health services, nonspecialty medical services, and care coordination services.
Proponents argue
Proponents argue that eliminating cost sharing for initial primary care visits will remove a significant financial barrier, encouraging beneficiaries to seek preventive care, early diagnosis, and ongoing management of health conditions, including mental and behavioral health. This proactive approach could lead to better health outcomes, reduce the need for more expensive emergency care, and address health disparities by ensuring equitable access to essential services.
Opponents contend
Opponents might raise concerns about the potential fiscal impact on federal and state budgets due to increased utilization and reduced revenue from cost sharing. They might also argue that while the intent is good, a blanket waiver for three visits might not be the most targeted or efficient way to address access issues, and could lead to overutilization of services or strain existing primary care provider capacity.
The bill is very short and straightforward, allowing ample time for a thorough understanding of its provisions.
Section 2(a)(1)(A) and (B)
Eliminating Medicare Part B Cost Sharing for First 3 Primary Care Visits
This provision amends Section 1833 of the Social Security Act to ensure that Medicare Part B will pay 100% of the approved amount for the first three primary care visits each year, starting in 2026. This means beneficiaries will not have to pay deductibles, copayments, or coinsurance for these initial visits, effectively removing out-of-pocket costs at the point of service.
Supporters argue
Supporters argue this removes a significant financial barrier, encouraging beneficiaries to seek necessary primary and preventive care, leading to earlier detection and management of health issues, and ultimately better health outcomes.
Critics contend
Critics might argue this could lead to increased federal spending due to higher utilization rates and reduced beneficiary contributions, potentially straining the Medicare trust fund without clear evidence of proportional health improvements.
Tradeoffs
Balances the goal of improving access to care and preventive services against potential increases in federal healthcare expenditures and the administrative burden of tracking visit counts.
Section 2(a)(2)
Eliminating Medicare Advantage Cost Sharing for First 3 Primary Care Visits
This section amends Section 1852 of the Social Security Act to require Medicare Advantage plans to also cover the first three primary care visits annually without cost sharing, beginning in 2026. This ensures that beneficiaries enrolled in private Medicare plans receive the same benefit as those in traditional Medicare, maintaining parity in access to these essential services.
Section 2(a)(3)
Defining 'Primary Care Visit'
This provision adds a new subsection (nnn) to Section 1861 of the Social Security Act, defining 'primary care visit' for the purposes of this Act. It broadly includes 'outpatient mental and behavioral health services, nonspecialty medical services, and care coordination services furnished for the prevention, diagnosis, treatment, or management of a physical, mental, or behavioral health condition.' This broad definition ensures comprehensive coverage.
Section 2(b)(1) and (2)
Eliminating Medicaid Cost Sharing for First 3 Primary Care Visits
This section amends Sections 1916 and 1916A of the Social Security Act to prohibit states from imposing cost sharing (premiums, deductibles, copayments, coinsurance) for the first three primary care visits for Medicaid beneficiaries, starting in 2026. This extends the same cost-sharing relief to low-income individuals covered by Medicaid, further enhancing access to essential primary care services.