HR 1096119th CongressIn Committee

HOPE and Mental Wellbeing Act of 2025

Introduced: Feb 6, 2025

Standard Summary

Comprehensive overview in 1-2 paragraphs

The HOPE and Mental Wellbeing Act of 2025 would require Medicare and Medicaid programs to cover the first three primary care visits a person receives in a year without any cost sharing, starting in 2026. The term “primary care visit” is defined broadly to include outpatient mental and behavioral health services, nonspecialty medical services, and care coordination services intended for prevention, diagnosis, treatment, or management of physical or mental health conditions. The bill would apply to traditional Medicare, Medicare Advantage plans, and Medicaid/Medicaid programs, with the intent of expanding access to preventive and mental health care by eliminating copays or similar cost-sharing for these initial three visits each year. The overall idea is to reduce barriers to early care and improve outcomes, particularly in mental health and integrated care.

Key Points

1Repeats and expands coverage: The first three primary care visits per year, as defined (including mental/behavioral health, nonspecialty medical services, and care coordination), would be covered without cost sharing for Medicare beneficiaries (Part B and MA plans) beginning in 2026, with payment structured so the insurer pays amounts up to the standard outpatient payment rate.
2Medicare specifics: For the first three visits, the amount paid by Medicare would be 100% of the lesser of the actual charge or the payment amount under the applicable outpatient payment provision, effectively eliminating cost sharing for those visits.
3Medicaid expansion: The first three primary care visits per year would also be covered without cost sharing under Medicaid, with analogous amendments to Medicaid’s cost-sharing rules to remove copays for those visits starting in 2026.
4Definition of primary care visit: Expanded to include outpatient mental and behavioral health services, nonspecialty medical services, and care coordination services used to prevent, diagnose, treat, or manage physical or mental/behavioral health conditions.
5Implementation scope: The bill adds the new coverage to both traditional Medicare and Medicare Advantage, and applies similarly to Medicaid, including provisions related to alternative cost-sharing arrangements.

Impact Areas

Primary group/area affected: Medicare beneficiaries (including older adults and certain disabled individuals) and Medicaid beneficiaries, particularly those relying on primary care and mental health services.Secondary group/area affected: Primary care and behavioral health providers, clinics, and health systems that bill for outpatient visits; federal and state payers (Medicare and Medicaid) facing potential budgetary and administrative changes to implement no-cost-sharing for these visits.Additional impacts: Potential changes in health outcomes through increased access to early and preventive care, potential uptick in utilization of mental health and care coordination services, and administrative efforts to track the “first 3 visits per year” per patient across programs beginning in 2026. Budgetary implications for federal and state levels, as well as potential effects on health equity and patient financial protection.

Generated by gpt-5-nano on Nov 1, 2025