II 118th CONGRESS 2d Session S. 4835 IN THE SENATE OF THE UNITED STATES July 30, 2024 Mr. King introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL 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.

1. Short title This Act may be cited as 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 (a) ERISA (1) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq. ) is amended by inserting after section 720 the following new section: 721. Coverage of certain primary care and behavioral health care visits (a) In general In addition to any item or service described in section 2713(a) of the Public Health Service Act, a group health plan, and a health insurance issuer offering group health insurance coverage, shall at a minimum provide coverage for and shall not impose any cost-sharing requirements for, with respect to a plan year— (1) 3 primary care visits; and (2) 3 behavioral health care visits. (b) Limitations A group health plan, and a health insurance issuer offering group health insurance coverage, shall ensure that— (1) the treatment limitations applicable to the 3 primary care visits described in paragraph (1) of subsection (a) and the 3 behavioral health care visits described in paragraph (2) of such subsection are no more restrictive than the treatment limitations applied to any other primary care visit or behavioral health care visit covered by the plan or coverage and that there are no separate treatment limitations that are applicable only with respect to such 3 primary or such 3 behavioral health care visits; and (2) the reimbursement rates under such plan or such coverage for such 3 primary and such 3 behavioral health care visits are the same as such rates for any other primary care visit or behavioral health care visit covered by the plan or coverage. (c) Definitions For purposes of this section: (1) Behavioral health care visit The term behavioral health care visit means a visit by an individual to a qualified provider during which services are provided with respect to the diagnosis, treatment, screening, or prevention of a behavioral health condition. (2) Primary care service The term primary care service means a service identified, as of January 1, 2009, by one of HCPCS codes 99201 through 99215 (and as subsequently modified by the Secretary). (3) Primary care visit The term primary care visit means an in-person visit by an individual to a qualified provider who is designated by such individual as the primary care provider for such individual, during which such individual receives primary care services. (4) Qualified provider The term qualified provider means— (A) with respect to a primary care visit, a general practitioner, family physician, general internist, obstetrician-gynecologist, pediatrician, geriatric physician, or physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife); and (B) with respect to a behavioral health care visit, an individual employed in a full-time position (including a fellowship) where the primary intent and function of such position is the direct treatment or recovery support of individuals with, or in recovery from, a behavioral health disorder, such as a physician, physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife), psychiatric nurse, social worker, marriage and family therapist, mental health counselor, occupational therapist, psychologist, psychiatrist, child and adolescent psychiatrist, or neurologist. . (2) Conforming amendment The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1001 et seq. ) is amended by inserting after the item relating to section 720 the following new item: Sec. 721. Coverage of certain primary care and behavioral health care visits. . (b) PHSA Part D of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq. ) is amended by inserting after section 2799A–5 the following new section: 2799A–6. Coverage of certain primary care and behavioral health care visits (a) In general In addition to any item or service described in section 2713(a), a group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall at a minimum provide coverage for and shall not impose any cost-sharing requirements for, with respect to a plan year— (1) 3 primary care visits; and (2) 3 behavioral health care visits. (b) Limitations A group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall ensure that— (1) the treatment limitations applicable to the 3 primary care visits described in paragraph (1) of subsection (a) and the 3 behavioral health care visits described in paragraph (2) of such subsection are no more restrictive than the treatment limitations applied to any other primary care visit or behavioral health care visit covered by the plan or coverage and that there are no separate treatment limitations that are applicable only with respect to such 3 primary or such 3 behavioral health care visits; and (2) the reimbursement rates under such plan or such coverage for such 3 primary and such 3 behavioral health care visits are the same as such rates for any other primary care visit or behavioral health care visit covered by the plan or coverage. (c) Definitions For purposes of this section: (1) Behavioral health care visit The term behavioral health care visit means a visit by an individual to a qualified provider during which services are provided with respect to the diagnosis, treatment, screening, or prevention of a behavioral health condition. (2) Primary care service The term primary care service means a service identified, as of January 1, 2009, by one of HCPCS codes 99201 through 99215 (and as subsequently modified by the Secretary). (3) Primary care visit The term primary care visit means an in-person visit by an individual to a qualified provider who is designated by such individual as the primary care provider for such individual, during which such individual receives primary care services. (4) Qualified provider The term qualified provider means— (A) with respect to a primary care visit, a general practitioner, family physician, general internist, obstetrician-gynecologist, pediatrician, geriatric physician, or physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife); and (B) with respect to a behavioral health care visit, an individual employed in a full-time position (including a fellowship) where the primary intent and function of such position is the direct treatment or recovery support of individuals with, or in recovery from, a behavioral health disorder, such as a physician, physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife), psychiatric nurse, social worker, marriage and family therapist, mental health counselor, occupational therapist, psychologist, psychiatrist, child and adolescent psychiatrist, or neurologist. . (c) IRC (1) In general Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by inserting after section 9820 the following new section: 9821. Coverage of certain primary care and behavioral health care visits (a) In general In addition to any item or service described in section 2713(a) of the Public Health Service Act, a group health plan shall at a minimum provide coverage for and shall not impose any cost-sharing requirements for, with respect to a plan year— (1) 3 primary care visits; and (2) 3 behavioral health care visits. (b) Limitations A group health plan shall ensure that— (1) the treatment limitations applicable to the 3 primary care visits described in paragraph (1) of subsection (a) and the 3 behavioral health care visits described in paragraph (2) of such subsection are no more restrictive than the treatment limitations applied to any other primary care visit or behavioral health care visit covered by the plan and that there are no separate treatment limitations that are applicable only with respect to such 3 primary or such 3 behavioral health care visits; and (2) the reimbursement rates under such plan for such 3 primary and such 3 behavioral health care visits are the same as such rates for any other primary care visit or behavioral health care visit covered by the plan. (c) Definitions For purposes of this section: (1) Behavioral health care visit The term behavioral health care visit means a visit by an individual to a qualified provider during which services are provided with respect to the diagnosis, treatment, screening, or prevention of a behavioral health condition. (2) Primary care service The term primary care service means a service identified, as of January 1, 2009, by one of HCPCS codes 99201 through 99215 (and as subsequently modified by the Secretary). (3) Primary care visit The term primary care visit means an in-person visit by an individual to a qualified provider who is designated by such individual as the primary care provider for such individual, during which such individual receives primary care services. (4) Qualified provider The term qualified provider means— (A) with respect to a primary care visit, a general practitioner, family physician, general internist, obstetrician-gynecologist, pediatrician, geriatric physician, or physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife); and (B) with respect to a behavioral health care visit, an individual employed in a full-time position (including a fellowship) where the primary intent and function of such position is the direct treatment or recovery support of individuals with, or in recovery from, a behavioral health disorder, such as a physician, physician assistant or advanced practice registered nurse acting in accordance with State law (including a nurse practitioner, clinical nurse specialist, and certified nurse midwife), psychiatric nurse, social worker, marriage and family therapist, mental health counselor, occupational therapist, psychologist, psychiatrist, child and adolescent psychiatrist, or neurologist. . (2) High deductible health plans Section 223(c)(2)(C) of the Internal Revenue Code of 1986 is amended by inserting or for providing coverage for the visits described in section 9821 before the period. (3) Conforming amendment The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by inserting after the item relating to section 9820 the following new item: Sec. 9821. Coverage of certain primary care and behavioral health care visits. . (d) Effective date The amendments made by this section shall apply with respect to plan years beginning on or after the date that is 2 years after the date of the enactment of this Act.