Overview
Title
To amend the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to require group health plans and health insurance issuers offering group or individual health insurance coverage to provide for 3 primary care visits and 3 behavioral health care visits without application of any cost-sharing requirement.
ELI5 AI
Imagine a rule that says everyone with a special kind of health insurance can visit the doctor or a counselor three times a year without paying any money when they go. This bill tries to make that a real rule for everyone, so it's easier for people to get help when they’re sick or need to talk to someone.
Summary AI
H.R. 9133 aims to amend several significant acts, including the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code, to ensure better healthcare access for individuals. The bill mandates that group health plans and health insurance companies provide at least three primary care visits and three behavioral health care visits per year without any cost-sharing, such as deductibles or co-pays. This provision applies equally across different acts, seeking to remove financial barriers to essential healthcare services, effective two years after the bill's enactment.
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AnalysisAI
The House of Representatives introduced H.R. 9133, a bill that, if passed, will amend existing health care-related laws in the United States. This legislation aims to increase access to health care by requiring group and individual health insurance plans to cover three primary care visits and three behavioral health care visits annually, without any cost-sharing for patients. This means insured individuals would not have to pay out of their pocket for these visits, regardless of their insurance plan's typical policy on co-pays or deductibles.
Summary of Significant Issues
Several issues have surfaced in the analysis of this bill. Firstly, while the bill promotes cost-free access to essential healthcare services, it does not address how removing cost-sharing would affect insurance premiums or the cost of other health services. This omission could mean higher premiums or limited coverage in other health areas to offset these 'free' visits.
Additionally, there is potential confusion due to the use of Healthcare Common Procedure Coding System (HCPCS) codes from 2009 to define "primary care services." These codes may no longer align with current medical practices or the codes insurers currently use, leading to inconsistencies in what services are covered without cost-sharing across different insurance providers.
Moreover, the bill applies different standards within three significant areas of U.S. law: the Employee Retirement Income Security Act (ERISA), the Public Health Service Act (PHSA), and the Internal Revenue Code (IRC). These varying standards could potentially create inefficiencies or discrepancies in how the bill is implemented and enforced, leading to challenges in compliance for insurers and confusion for insured individuals.
The definition of a "behavioral health care visit" is broad and leaves room for interpretation, which may lead to inconsistent standards and confusion over what qualifies as a covered visit. For instance, mental health professionals might have different views on what constitutes a behavioral health condition, affecting whether patients get coverage for specific treatments.
Impact on the Public
The implications of this bill on the general public are considerable. For individuals and families, the potential for accessing critical primary and behavioral health care services without incurring hefty out-of-pocket costs is undeniably positive. This could remove financial barriers that deter people from seeking preventative care or mental health support, potentially leading to healthier outcomes.
However, without clarity on who will bear the cost of these no-cost visits, the public might face increased insurance premiums or a decrease in other covered services. For some individuals, particularly those who do not require frequent visits, this could result in higher healthcare costs overall.
Impact on Specific Stakeholders
Patients stand to benefit from enhanced access to essential care without immediate financial concern. Those struggling with mental health issues or in need of regular checkups may find this bill particularly advantageous.
Health Insurance Companies face challenges as they must adjust their plans to include these visits without cost-sharing. This might require administrative changes and possibly lead to an increase in premiums or reduced service coverage to recoup lost revenue from co-pays and deductibles.
Healthcare Providers, especially those offering primary and behavioral healthcare services, may see an increase in patient visits. While this can be a positive development, it could also lead to strained capacity and longer wait times for appointments if the demand exceeds current supply.
Overall, H.R. 9133 presents an opportunity to enhance access to vital healthcare services for many, but it also poses logistical, financial, and regulatory challenges that require careful consideration and planning by all stakeholders involved.
Issues
The bill mandates 3 primary care visits and 3 behavioral health care visits without cost-sharing but does not specify how these costs will be covered or whether this will lead to increased premiums or reduced coverage in other areas, which might financially impact policyholders. (Sections 2, 721, 2799A-6, 9821)
The use of HCPCS codes from January 1, 2009, to define 'primary care service' may lead to confusion and inconsistency as these codes may no longer reflect current medical practices or coverage requirements. (Sections 2, 721, 2799A-6, 9821)
Different standards across various legal areas (ERISA, PHSA, IRS) might cause inconsistencies in implementation or enforcement, potentially leading to compliance challenges. (Sections 2, 721, 2799A-6, 9821)
The broad definition of 'behavioral health care visit' could lead to varying interpretations, affecting reimbursement and coverage, as different providers might have different standards for what constitutes such a visit. (Sections 2, 721, 2799A-6, 9821)
The effective date of two years after enactment may not allow sufficient time for health plans and stakeholders to adjust coverage and billing systems, leading to potential compliance and operational issues. (Section 2)
There is a lack of clear criteria or mechanisms for determining reimbursement rates for the specified visits, which could result in disputes between providers and insurers. (Sections 721, 2799A-6, 9821)
The potential for increased administrative costs for health plans to adjust systems to comply with the new requirements is not addressed, which could lead to unforeseen financial impacts on insurers and indirectly on policyholders. (Sections 2, 721, 2799A-6, 9821)
Sections
Sections are presented as they are annotated in the original legislative text. Any missing headers, numbers, or non-consecutive order is due to the original text.
1. Short title Read Opens in new tab
Summary AI
The first section of the act states that the official name of the law is the “Primary and Behavioral Health Care Access Act of 2024”.
2. Prohibition on application of cost sharing for certain primary care and behavioral health care visits Read Opens in new tab
Summary AI
The section prohibits the application of cost-sharing for three primary care visits and three behavioral health care visits per year under group health plans and insurance coverage, ensuring these visits have the same treatment limitations and reimbursement rates as others. This measure aims to make these visits more accessible without extra costs, and it includes definitions for terms like "behavioral health care visit", "primary care service", "primary care visit", and "qualified provider".
721. Coverage of certain primary care and behavioral health care visits Read Opens in new tab
Summary AI
The section mandates that health insurance plans must cover at least three primary care visits and three behavioral health care visits per year without cost-sharing. It also ensures these visits have the same treatment limits and reimbursement rates as other similar visits, and it defines terms like "behavioral health care visit" and "qualified provider."
2799A–6. Coverage of certain primary care and behavioral health care visits Read Opens in new tab
Summary AI
Under this section, health insurance plans must cover at least three primary care visits and three behavioral health care visits each year without charging patients. The rules for these visits must be the same as other similar visits in terms of restrictions and payment rates.
9821. Coverage of certain primary care and behavioral health care visits Read Opens in new tab
Summary AI
A group health plan must cover at least three primary care and three behavioral health care visits each year without charging the patient. The rules for these visits should be the same as for any other similar visits, including how much the healthcare providers are paid.