H.R.1096 amends the Social Security Act to eliminate beneficiary cost-sharing for the first three primary care visits per year in Medicare (including Medicare Advantage) and in Medicaid, beginning in 2026. The bill adds a new statutory definition of “primary care visit” that explicitly includes outpatient mental and behavioral health services, nonspecialty medical services, and care coordination.
This is a targeted benefit-change aimed at lowering financial barriers to early primary and mental health care for Medicare and Medicaid populations. It will change billing and benefit design for Part B and Medicare Advantage plans, and requires states to exempt these visits from Medicaid cost-sharing and from alternative cost-sharing arrangements under section 1916A.
At a Glance
What It Does
The bill revises multiple sections of the Social Security Act so that Medicare pays the full allowable amount for the first three primary care visits an enrollee receives each year and those visits are exempt from Part B deductible and coinsurance; Medicare Advantage plans must include them as covered services. For Medicaid, states must exempt those same first three visits from beneficiary cost-sharing, including within approved alternative cost-sharing programs.
Who It Affects
Directly affects Medicare Part B beneficiaries, Medicare Advantage enrollees, Medicaid recipients, Medicare Advantage organizations, state Medicaid programs, and outpatient providers who bill for primary care and outpatient mental/behavioral health services. CMS will have to issue operational guidance; states must update their Medicaid cost-sharing policies.
Why It Matters
By embedding mental and behavioral health into the primary-care benefit and removing up-front cost barriers, the bill could increase early access to care and shift utilization patterns toward outpatient primary and behavioral health. It also creates immediate implementation questions for payers and providers — how to define, code, track, and reimburse those visits across settings — and will affect federal and state program spending.
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What This Bill Actually Does
H.R.1096 makes a narrow but material change to how Medicare and Medicaid handle cost-sharing for routine outpatient care. For Medicare Part B the bill amends section 1833 so that, beginning in 2026, the program (not the beneficiary) pays 100% of the lesser of the provider’s actual charge or the otherwise applicable outpatient payment amount for the first three “primary care visits” furnished to an individual each year.
The bill also adjusts the deduction/coinsurance language so those initial visits are not subject to the Part B deductible or coinsurance. For Medicare Advantage, the statute adds the same three-visit exemption to the list of benefits MA plans must cover.
To avoid ambiguity about scope, the bill adds a new definition to section 1861: a “primary care visit” includes outpatient mental and behavioral health services, nonspecialty medical services, and care coordination services tied to prevention, diagnosis, treatment, or management of a physical, mental, or behavioral health condition. That definition intentionally pulls mental and behavioral health into the same counting bucket as other routine primary care encounters.On the Medicaid side, the bill amends section 1916 to exclude the first three primary care visits per year from allowable beneficiary cost-sharing, and it adds the same exclusion into the alternative cost-sharing rules at section 1916A.
Practically, states operating Medicaid must update plan cost-sharing schedules and managed-care contracts to ensure those visits are exempt; CMS will need to confirm how the exclusions interact with existing nominal fee limitations and state waivers.Operationally the statute creates several immediate administrative needs. Providers and payers must identify which encounters meet the statutory definition, apply the exemption to the first three visits only, and prevent duplicate counting across care settings and plan types.
The bill does not create a new payment rate or separate appropriation — it directs existing program payments to cover the visits — so CMS, Medicare Advantage organizations, and states will need to absorb the spending changes within current benefit and budget structures. The definition’s breadth and lack of coding detail mean CMS rulemaking or guidance will be necessary to make the rule workable in day-to-day claims processing.
The Five Things You Need to Know
The bill takes effect beginning in 2026 and applies to the first three primary care visits furnished to an individual during each year.
It amends Medicare payment law so Medicare must pay 100% of the lesser of the actual charge or the otherwise applicable outpatient payment amount for those first three visits under Part B.
The statute adds a new definition of “primary care visit” that explicitly covers outpatient mental and behavioral health services, nonspecialty medical services, and care coordination.
Medicare Advantage plans are required to include the first three primary care visits as covered services, meaning enrollees in MA get the same no-cost-first-three benefit.
For Medicaid, the bill bars states from charging cost-sharing (including under alternative cost-sharing arrangements) for an enrollee’s first three primary care visits each year.
Section-by-Section Breakdown
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Short title
Designates the act as the "Helping Out Patients for Emotional and Mental Wellbeing Act" or the "HOPE and Mental Wellbeing Act of 2025." This is the only nominal provision and has no operational effect.
Full payment and cost-sharing exemption for first three Part B visits
Modifies section 1833 to require that, starting in 2026, Medicare pay 100% of the lesser of the provider's charge or the recognized outpatient payment amount for an individual's first three primary care visits each year under applicable outpatient payment provisions. It also changes subsection (b) so the Part B deductible and coinsurance rules do not apply to those visits. Practically, providers will receive the allowed payment with beneficiaries owing no Part B cost-sharing for up to three qualifying visits annually; billing systems will need logic to apply the exemption only to a beneficiary's first three qualifying claims within the calendar year.
Mandates MA plans cover the first three primary care visits
Inserts the first three primary care visits into the enumerated list of services Medicare Advantage plans must provide. This ensures MA enrollees receive these visits without cost-sharing under plan benefits, not left to supplemental benefit design choices. Insurers will need to reflect the coverage in member materials and claims adjudication.
Defines 'primary care visit' to include mental/behavioral health and care coordination
Adds a statutory definition that covers outpatient mental and behavioral health services, nonspecialty medical services, and care coordination used for prevention, diagnosis, treatment, or management of physical, mental, or behavioral conditions. The broad phrasing intentionally places a range of outpatient encounters into the primary-care category, which affects which claims count toward the three-visit exemption and will be central to CMS guidance and coding rules.
Exempts first three primary care visits from Medicaid cost-sharing and alternative cost-sharing
Adds the first three primary care visits per year to the list of services states may not impose cost-sharing on under section 1916, and inserts the same exclusion into section 1916A's alternative cost-sharing rules. States operating nominal fee structures or managed-care contracts must update their cost-sharing schedules and beneficiary notices to reflect the exemption, and will likely need to adjust their actuarial and budget projections to account for the coverage change.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Medicare Part B beneficiaries who need primary or mental health care — they see reduced upfront financial barriers for early outpatient visits, which can increase access to diagnosis and management of mental and chronic conditions.
- Medicare Advantage enrollees — MA members will receive parity with traditional Part B beneficiaries because MA plans must cover the first three visits without cost-sharing.
- Medicaid enrollees in states that currently impose nominal cost-sharing — those individuals will gain exemption for up to three qualifying visits each year, removing a common barrier to care for low-income populations.
- Primary care clinicians and outpatient behavioral health providers — increased patient engagement for early-stage problems may drive higher visit volume and better continuity of care, and the statutory requirement clarifies that such visits fall within covered benefits.
Who Bears the Cost
- Medicare program (Part B/Trust Fund) — paying 100% of allowable charges for additional visits increases program outlays; the bill does not appropriate new funds or specify offsets.
- State Medicaid programs and budgets — states must absorb the fiscal effects of waived cost-sharing through higher program spending or reallocation, subject to federal matching rules.
- Medicare Advantage organizations and commercial plan administrators — plans must cover the benefit and may face higher utilization and administrative costs updating benefit design and claims systems.
- Providers and billing departments — they will face implementation costs to change coding, claims edits, and tracking systems to correctly apply the three-visit exemption and distinguish qualifying encounters.
Key Issues
The Core Tension
The bill balances two legitimate goals — expanding low-barrier access to early primary and mental health care, and keeping program spending and administrative complexity manageable — but solving one increases pressure on the other: removing cost-sharing improves access and uptake, yet the broad definition and lack of financing or coding detail raise risks of increased utilization, ambiguous implementation, and budgetary strain without clear guardrails.
The bill creates clear access gains but leaves several operational and fiscal questions unresolved. The statutory definition of “primary care visit” is deliberately broad; without accompanying coding and encounter-level guidance from CMS, payers and providers will disagree about which claims qualify.
The statute does not specify whether telehealth, team-based visits, or certain bundled outpatient services count as a single visit, nor does it identify the claim lines or modifiers providers should use to trigger the exemption. Those ambiguities create a risk of inconsistent application and retrospective claim adjustments.
On the fiscal side, H.R.1096 directs program payments to cover the visits but does not identify offsets or new funding. That shifts cost pressure onto the Medicare trust funds, Medicare Advantage capitation budgets, and state Medicaid budgets.
States and plans may respond by narrowing covered visit definitions in practice, tightening utilization management on other services, or restructuring supplemental benefits. Finally, because the bill applies only to the “first three” visits, it creates a cliff: beneficiaries have strong incentive to front-load care or to have encounters coded as qualifying primary care visits, which may invite coding disputes and potential gaming unless CMS defines precise rules for counting visits and for cross-setting aggregation (for example, visits delivered in FQHCs, physician offices, or via telehealth).
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