HOPE and Mental Wellbeing Act of 2025

Bill Number

H.R. 1096

Origin Chamber

House

Congress

119th Congress, Session 1

Policy Area

Health

Status

Introduced

Latest Action

2025-02-06: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.

Last Updated

2025-04-28T20:21:20Z

AI-Generated Summary

Purpose

The HOPE and Mental Wellbeing Act of 2025 aims to improve access to primary care by eliminating out-of-pocket costs for the first three primary care visits each year for beneficiaries under Medicare and Medicaid programs. This focuses on preventive and ongoing care for physical, mental, and behavioral health conditions to support early intervention and overall wellbeing.

Key Provisions

• Coverage Under Medicare:
• Requires Medicare to pay 100% of the cost for the first three primary care visits per year starting in 2026, with no deductibles, copayments, or other cost-sharing required from the beneficiary.
• Applies to visits covered under standard Medicare outpatient payment rules.
• Extends the same no-cost-sharing benefit to Medicare Advantage plans (private plans that provide Medicare benefits).
• Coverage Under Medicaid:
• Prohibits states from imposing cost-sharing (such as copays or deductibles) on the first three primary care visits per year starting in 2026.
• Includes provisions for alternative cost-sharing arrangements under Medicaid, ensuring these visits remain free.
• Definition of Primary Care Visit:
• Defined as outpatient services including mental and behavioral health care, non-specialist medical services, and care coordination for preventing, diagnosing, treating, or managing physical, mental, or behavioral health conditions. (This broad definition covers routine check-ups, therapy sessions, and coordination of care but excludes specialist visits like those with cardiologists or psychiatrists unless they fit the criteria.)

Significant Changes to Existing Law

• Amends Section 1833 of the Social Security Act (governing Medicare payments) to waive cost-sharing for these visits, overriding existing rules that typically require beneficiaries to pay 20% coinsurance for outpatient services after meeting a deductible.
• Modifies Section 1852 for Medicare Advantage plans to include these visits in the list of services that must be covered without cost-sharing.
• Updates Sections 1916 and 1916A of the Social Security Act (governing Medicaid cost-sharing) to exempt these visits from any state-imposed fees, building on prior expansions like those for preventive services under the Affordable Care Act.
• Adds a new definition in Section 1861(nnn), which did not previously exist, to clarify what qualifies as a primary care visit and emphasize mental health integration.

Potential Impacts

• On Citizens: Medicare and Medicaid beneficiaries (primarily seniors aged 65+, people with disabilities, and low-income individuals) will face no financial barriers for initial primary care visits, potentially increasing use of preventive services and early mental health support. This could reduce overall health costs by catching issues early but might lead to higher program spending if utilization rises.
• On Government Agencies: The Centers for Medicare & Medicaid Services (CMS) will need to update payment systems, provider guidelines, and beneficiary notices to implement the changes by 2026. States administering Medicaid may see administrative burdens and shifts in funding, as federal matching funds cover most costs. No direct impact on international relations.
• Broader Effects: Could lower emergency room visits and hospitalizations by promoting routine care, yielding long-term savings for federal and state budgets despite initial increased payouts.

Main Stakeholders Affected

• Beneficiaries: Medicare enrollees (about 65 million people) and Medicaid recipients (over 80 million, including children and low-income adults), who gain free access to essential care.
• Healthcare Providers: Primary care doctors, mental health counselors, and care coordinators, who may see more patients without billing hassles for these visits.
• Insurers and Plans: Medicare Advantage organizations must comply without passing costs to enrollees, potentially affecting plan premiums.
• Governments: Federal government (via CMS and Treasury for funding) and state Medicaid agencies, which share costs and implementation responsibilities.

Notable Legal, Constitutional, or Political Implications

• Legal: As an amendment to the Social Security Act, it expands entitlement benefits without altering eligibility rules, fitting within Congress's authority over federal spending programs. Implementation relies on CMS rulemaking, which could face challenges if definitions (e.g., what counts as "care coordination") lead to disputes over coverage.
• Constitutional: No apparent conflicts; it promotes equal access to health services under the general welfare clause but could raise equal protection questions if applied unevenly across states in Medicaid.
• Political: Aligns with bipartisan efforts to address mental health crises post-COVID, potentially reducing healthcare disparities. As a budget-neutral initiative in intent (via preventive savings), it may influence future appropriations debates, but critics might argue it increases federal spending without offsets. The bill's referral to key committees (Energy and Commerce, Ways and Means) signals scrutiny on fiscal impacts.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Salinas, Andrea [D-OR-6]

Cosponsors (7)

Rep. Watson Coleman, Bonnie [D-NJ-12], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Doggett, Lloyd [D-TX-37], Rep. Goldman, Daniel S. [D-NY-10], Rep. Tonko, Paul [D-NY-20], Rep. Tokuda, Jill N. [D-HI-2], Rep. Stansbury, Melanie A. [D-NM-1]

Recent Actions

• 2025-02-06: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
• 2025-02-06: Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
• 2025-02-06: Introduced in House
• 2025-02-06: Introduced in House

Bill Versions

• Helping Out Patients for Emotional and Mental Wellbeing Act — issued 2025-02-06 — PDF (5 pages)