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
S. 4835 wants to make sure everyone with health insurance can visit a doctor and a therapist three times a year without paying extra money like co-pays, but it might take a couple of years to start, and it doesn't say how to make sure everyone follows the rules.
Summary AI
S. 4835 aims to amend several existing laws to require group health plans and health insurance providers to offer a minimum of three primary care visits and three behavioral health care visits per year without any cost-sharing by the patient. This means individuals can access these specific healthcare services without having to pay out-of-pocket expenses like co-pays or deductibles for those visits. The bill seeks to ensure that there are no additional restrictions or lower reimbursement rates specifically for these visits compared to other healthcare services covered by the plans. The proposed changes would become effective two years after the bill is enacted.
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AnalysisAI
The bill titled "Primary and Behavioral Health Care Access Act of 2024" is designed to amend several existing laws related to health care coverage, including the Employee Retirement Income Security Act of 1974, the Public Health Service Act, and the Internal Revenue Code of 1986. It aims to mandate that group health plans and health insurance issuers provide at least three primary care visits and three behavioral health care visits each year without requiring patients to pay any cost-sharing fees like co-pays or deductibles.
General Summary
This legislative proposal seeks to enhance access to health care, specifically primary and behavioral health services, by eliminating out-of-pocket expenses for a limited number of visits. By removing financial barriers for these six annual visits, the bill could promote preventive care and early intervention, both of which are key to improving individual and public health outcomes.
Significant Issues
The bill outlines several important issues, beginning with the broad and possibly ambiguous qualifications for behavioral health care providers. Without clear eligibility criteria for these providers, there may be inconsistencies and variations in the quality of care patients receive. Furthermore, defining a 'visit' only as an in-person appointment excludes telehealth options, which are increasingly important for accessibility and public health, especially post-pandemic.
Another concern is how reimbursement rates for these no-cost visits will be determined. The bill stipulates that rates should be the same as for other visits, yet lacks detail on implementation or adjustment mechanisms, which could lead to conflicts between insurers and providers over fair compensation.
Additionally, the effective date of two years after enactment poses a delay in benefits reaching the populace, yet the bill does not provide a rationale for this timeline. Furthermore, there is no mention of budget implications, which raises concerns about unforeseen financial impacts on insurance plans and healthcare systems.
Impact on the Public
For the public at large, the bill appears to offer direct benefits by reducing out-of-pocket healthcare costs. The ability to access essential health services without additional financial burden may improve health outcomes and encourage individuals, particularly those hesitant due to cost, to seek necessary care.
Impact on Stakeholders
Patients: Patients who might struggle with healthcare costs would likely benefit significantly. However, those needing more frequent visits might not find the bill entirely adequate if these restrictions limit ongoing care management, particularly in mental health.
Healthcare Providers: Providers could face challenges relating to how the number of visits is tracked and ensuring compliance with reimbursement requirements. The expanded role of 'qualified providers' for behavioral health care visits underscores the necessity for clear regulatory standards to maintain care quality.
Insurance Companies: While insurers might see increased utilization of services, the lack of cost-sharing may require them to recalibrate premium calculations or adjust other cost aspects to balance additional financial responsibilities.
By addressing these areas, the Primary and Behavioral Health Care Access Act of 2024 aims to expand healthcare access while navigating the complexities associated with cost-free service provision. Balancing these considerations will be essential for the effective implementation and success of the proposed changes.
Issues
The bill mandates the coverage of 3 primary care visits and 3 behavioral health care visits without cost-sharing, but does not specify the eligibility criteria or qualifications that behavioral health care providers must meet, leading to potential inconsistencies in care standards (Sections 2, 721, 2799A-6, 9821).
The effective date for these provisions is set two years after enactment, delaying the intended benefits significantly with no justification provided for this timeframe (Section 2).
The reimbursement rates for the mandated visits must be equivalent to other visits, but there is no clarification on how these rates will be determined or adjusted, which might cause discrepancies or disputes between providers and insurance plans (Sections 721, 2799A-6, 9821).
The definition of a 'primary care visit' restricts it to in-person consultations, which excludes telehealth visits, potentially limiting access for patients who benefit from remote care options (Sections 721, 2799A-6, 9821).
The bill does not specify mechanisms for monitoring or enforcing compliance with its coverage and reimbursement provisions, posing a risk of non-compliance by health plans (Sections 721, 2799A-6, 9821).
The HCPCS codes used to define primary care services date from January 1, 2009, which may be outdated, possibly affecting the relevance and scope of covered services (Sections 721, 2799A-6, 9821).
There are no budget constraints or financial implications mentioned for requiring no-cost visits, which could lead to unexpected expenses or cost adjustments in other areas (Section 2).
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 health plans from charging patients for a minimum of three primary care and three behavioral health care visits per year. It ensures these visits have no special limitations or different reimbursement rates compared to other similar visits, and this applies to group health and individual insurance coverage starting two years after the enactment of the bill.
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.