I
119THCONGRESS
1
STSESSION H. R. 1096
To amend title XVIII of the Social Security Act to require coverage of
3 primary care visits without cost sharing each year under the Medicare
program.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY6, 2025
Ms. S
ALINAS(for herself, Mrs. WATSONCOLEMAN, Ms. NORTON, Mr. DOG-
GETT, and Mr. GOLDMANof New York) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Ways and Means, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
A BILL
To amend title XVIII of the Social Security Act to require
coverage of 3 primary care visits without cost sharing
each year under the Medicare program.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Helping Out Patients 4
for Emotional and Mental Wellbeing Act’’ or the ‘‘HOPE 5
and Mental Wellbeing Act of 2025’’. 6
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SEC. 2. REQUIRING COVERAGE OF 3 PRIMARY CARE VISITS 1
WITHOUT COST SHARING EACH YEAR UNDER 2
MEDICARE. 3
(a) M
EDICARE.— 4
(1) I
N GENERAL.—Section 1833 of the Social 5
Security Act (42 U.S.C. 1395l) is amended— 6
(A) in subsection (a)(1)— 7
(i) by striking ‘‘and’’ before ‘‘(HH)’’; 8
and 9
(ii) by inserting before the semicolon 10
at the end the following: ‘‘, and (II) with 11
respect to the first 3 primary care visits 12
(as defined in section 1861(nnn)) fur-13
nished to an individual during a year (be-14
ginning with 2026) for which payment may 15
be made under a specified outpatient pay-16
ment provision described in subsection 17
(cc)(2), the amounts paid shall be 100 per-18
cent of the lesser of the actual charge or 19
the payment amount otherwise recognized 20
under such respective specified outpatient 21
payment provision for such visit’’; and 22
(B) in subsection (b), in the first sen-23
tence— 24
(i) by striking ‘‘and’’ before ‘‘(13)’’; 25
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(ii) in paragraph (13), by striking ‘‘..’’ 1
and inserting a period; and 2
(iii) by inserting before the period at 3
the end the following: ‘‘, and (13) shall not 4
apply with respect to the first 3 primary 5
care visits (as defined in section 6
1861(nnn)) furnished to an individual dur-7
ing a year (beginning with 2026) for which 8
payment may be made under a specified 9
outpatient payment provision described in 10
subsection (cc)(2)’’. 11
(2) M
EDICARE ADVANTAGE .—Section 12
1852(a)(1)(B) of the Social Security Act (42 U.S.C. 13
1395w–22(a)(1)(B)) is amended— 14
(A) in clause (iv)— 15
(i) by redesignating subclause (VIII) 16
as subclause (IX); and 17
(ii) by inserting after subclause (VII) 18
the following new subclause: 19
‘‘(VIII) the first 3 primary care 20
visits (as defined in section 21
1861(nnn)) furnished to an enrollee 22
during a year (beginning with 23
2026).’’; and 24
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(B) in clause (v), by striking ‘‘and (VII)’’ 1
and inserting ‘‘(VII), and (VIII)’’. 2
(3) D
EFINITION.—Section 1861 of the Social 3
Security Act (42 U.S.C. 1395x) is amended by add-4
ing at the end the following new subsection: 5
‘‘(nnn) P
RIMARYCAREVISIT.—The term ‘primary 6
care visit’ means outpatient mental and behavioral health 7
services, nonspecialty medical services, and care coordina-8
tion services furnished for the prevention, diagnosis, treat-9
ment, or management of a physical, mental, or behavioral 10
health condition.’’. 11
(b) M
EDICAID.— 12
(1) I
N GENERAL.—Section 1916 of the Social 13
Security Act (42 U.S.C. 1396o) is amended— 14
(A) in subsection (a)(2)— 15
(i) in subparagraph (I), by striking 16
‘‘or’’ at the end; 17
(ii) in subparagraph (J), by striking 18
‘‘; and’’ at the end and inserting ‘‘, or’’; 19
and 20
(iii) by adding at the end the fol-21
lowing new subparagraph: 22
‘‘(K) the first 3 primary care visits (as de-23
fined in section 1861(nnn)) furnished to an in-24
dividual during a year (beginning with 2026) 25
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for which payment may be made under this 1
title; and’’; and 2
(B) in subsection (b)(2)— 3
(i) in subparagraph (I), by striking 4
‘‘or’’ at the end; 5
(ii) in subparagraph (J), by striking 6
‘‘; and’’ at the end and inserting ‘‘, or’’; 7
and 8
(iii) by adding at the end the fol-9
lowing new subparagraph: 10
‘‘(K) the first 3 primary care visits (as de-11
fined in section 1861(nnn)) furnished to an in-12
dividual during a year (beginning with 2026); 13
and’’. 14
(2) A
PPLICATION TO ALTERNATIVE COST SHAR -15
ING.—Section 1916A(b)(3)(B) of the Social Security 16
Act (42 U.S.C. 1396o–1(b)(3)(B)) is amended by 17
adding at the end the following new clause: 18
‘‘(xv) The first 3 primary care visits 19
(as defined in section 1861(nnn)) fur-20
nished to an individual during a year (be-21
ginning with 2026).’’. 22
Æ
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