The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Appropriations
BILL: CS/SB 56
INTRODUCER: Banking and Insurance Committee and Senator Harrell
SUBJECT: Coverage for Skin Cancer Screenings
DATE: February 21, 2024
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Thomas Knudson BI Fav/CS
2. Sanders Betta AEG Favorable
3. Sanders Sadberry AP Pre-meeting
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/SB 56 requires all contracted state group health insurance plans and health maintenance
organizations (HMO) to cover and pay for annual skin cancer screenings performed by a Florida
licensed dermatologist. The bill prohibits a state group health insurance plan or HMO from
imposing any cost-sharing requirement for the annual skin cancer screening, including a
deductible, copayment, coinsurance, or any other type of cost-sharing. The provider conducting
the screening must be a dermatologist licensed as a medical doctor under chapter 458, F.S., or an
osteopathic physician licensed under chapter 459, F.S., or an advanced practice registered nurse
licensed under chapter 464, F.S., who is under the supervision of a dermatologist licensed under
chapters 458 F.S. or 459 F.S.
The bill requires payment for such annual skin cancer screenings to be consistent with the state
group health insurance plans’ or HMO’s payments for other preventive screenings. Additionally,
the bill prohibits all contracted state group health insurance plans or HMOs from bundling a
payment for a skin cancer screening with any other procedure or service, including an evaluation
or management visit, which is performed during the same office visit or subsequent office visit.
The bill has a negative impact to state revenues and expenditures. The Division of State Group
Insurance within the Department of Management Services (DMS) estimates the bill will result in
REVISED: BILL: CS/SB 56 Page 2
an annual increase of $416,503
1
to the state employee group health plan. See Section V., Fiscal
Impact Statement.
The bill provides an effective date of July 1, 2024.
II. Present Situation:
Background
Skin cancer is the most common cancer in the United States.
2
Approximately one in five
Americans will develop skin cancer in their lifetime.
3
It is estimated approximately 9,500 people
in the U.S. are diagnosed with skin cancer every day.
4
Nearly 20 Americans die from melanoma
every day.
5
Cancer is the second most common cause of death in the United States after heart
disease and in 2023, a total of 1.9 million new cancer cases were diagnosed. Of the estimated
new cancer cases in the United States, five percent were skin cancer cases.
6
It is estimated
8,290 people will die of melanoma in 2024.
7
Basal cell and squamous cell cancers are called nonmelanoma skin cancer, and are the most
common of skin cancers. Melanoma accounts for about one percent of skin cancers but causes a
large majority of skin cancer deaths.
8
The long-term survival rate of those diagnosed with skin
cancer after five years is high at 93.5 percent
9
and more than 1.4 million people were identified
in the United States in 2020 as living with this cancer.
10
The more localized the cancer is when it
is found, meaning the cancer has been confined to a primary spot, the higher the survival rate is
1
Telephone call from Jake Holmgreen, Deputy Director of Legislative Affairs, Department of Management Services, to Niki
Davis, Legislative Analyst, Senate Committee on Agriculture, Environment, and General Government (Feb. 1, 2024).
2
Guy GP, Thomas CC, et al., Vital signs: Melanoma incidence and mortality trends and projections – United States, 1982-
2030, MMWR Morb Mortal Wkly Rep. 2015; 64(21):591-596, National Library of Medicine, available at
https://pubmed.ncbi.nlm.nih.gov/26042651/ (last visited Jan. 29, 2024).
3
Sterns RS, Prevalence of a history of skin cancer in 2007: results of an incidence-based model, Arch Dermatol, 2010 Mar.;
146(3):279-282, National Library of Medicine, available at https://pubmed.ncbi.nlm.nih.gov/26042651/ (last visited
Jan. 29, 2024).
4
Rogers HW, Weinstock MA, et al., Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US
population, JAMA Dermatol, April 30, 2015, available at https://pubmed.ncbi.nlm.nih.gov/25928283/ (last visited
Jan. 29, 2024).
5
American Academy of Dermatology, Don’t let skin cancer sneak up on you, https://www.aad.org/public/diseases/skin-
cancer/find/at-risk#:~:text=is%20highly%20curable.-,Melanoma,die%20from%20melanoma%20every%20day (last visited
Jan 29, 2024). “Melanoma is the most deadly form of skin cancer and may suddenly appear without warning, but can also
develop from or near an existing mole. Melanoma is most common on the upper back, torso, lower legs, head and neck. If
detected early and treated properly, melanoma is highly treatable.”
6
American Cancer Society, Journals, CA: A Cancer Journal for Clinicians, Cancer statistics, 2023 (last visited
Jan. 29, 2024).
7
Skin Cancer Foundation, Skin Cancer Facts & Statistics, What You Need to Know: Melanoma,
https://www.skincancer.org/skin-cancer-information/skin-cancer-facts/ (last visited Jan. 29, 2024).
8
American Cancer Society, Key Statistics for Melanoma Skin Cancer, available at
https://www.cancer.org/cancer/types/melanoma-skin-cancer/about/key-
statistics.html#:~:text=Having%20lighter%20skin%20color%20is,in%20200)%20for%20Hispanic%20people (last visited
Jan. 29, 2024).
9
National Cancer Institute, Cancer Stat Facts: Melanoma of the Skin, available at
https://seer.cancer.gov/statfacts/html/melan.html (last visited Jan. 29, 2024).
10
National Cancer Institute, Cancer Stat Facts: Melanoma of the Skin, Prevalence of Cancer, available at
https://seer.cancer.gov/statfacts/html/melan.html (last visited Jan. 29, 2024). BILL: CS/SB 56 Page 3
compared to a cancer that has spread to the regional lymph nodes or metastasized to another
region of the body.
11
For Florida, the estimated new cases of melanoma skin cancer for 2024 is 9,880 with projected
deaths of 790 individuals.
12
Of the top five cities in the U.S. for skin cancer prevalence rate
in 2018, four were found in Florida – Sarasota-Bradenton (10 percent), Fort Pierce-Port St. Lucie
(9.5 percent), West Palm Beach-Boca Raton (9.5 percent), and Melbourne-Titusville-Palm Bay
(8.6 percent).
13
Skin Cancer Screening
During a skin cancer screening test, a doctor or nurse checks a patient’s skin for moles,
birthmarks, or other pigmented areas that may be abnormal in color, size, shape, or texture.
14
If
an area looks abnormal, a biopsy of the area may be done where the health care provider may
remove as much of the suspicious tissue as possible with a local excision.
15
A pathologist
reviews this tissue under a microscope to check for cancer cells.
16
In Illinois, where preventative skin cancer screenings are covered by health insurance companies,
a large dermatology practice reports a 99.15 percent (stage 0-2) early melanoma detection rate
compared to the industry average early melanoma detection rate of 83.0 percent.
17
This results in
a 97.9 percent five-year melanoma survival rate, compared to the industry-average 87.0 percent
five-year melanoma survival rate.
18
Regulation of Insurance in Florida
The Office of Insurance Regulation (OIR) regulates specified insurance products, insurers and
other risk bearing entities in Florida.
19
As part of their regulatory oversight, the OIR may
suspend or revoke an insurer’s certificate of authority under certain conditions.
20
The OIR is
responsible for examining the affairs, transactions, accounts, records, and assets of each insurer
11
National Cancer Institute, Cancer Stat Facts: Melanoma of the Skin, Survival by State, available at
https://seer.cancer.gov/statfacts/html/melan.html (last visited Jan. 29, 2024).
12
American Cancer Society, Cancer Statistics Center, Explore Cancer Statistics, 2024 Estimated New Cancer Cases and
Deaths By State: Melanoma of the skin (sexes combined, Florida) (data run on Jan. 29, 2024) available at Cancer Statistics Center
- American Cancer Society (last visited Jan. 29, 2024).
13
Blue Cross Blue Shield, National Labor Force, LABORMatters, The Health of America Report, July 2018, at 4,
https://www.bcbs.com/sites/default/files/file-attachments/page/Labor-Matters-July2018.pdf (last visited Jan. 29, 2024)
14
National Cancer Institute, Skin Cancer Screening (PDQ) – Patient Version, available at Skin Cancer Screening - NCI (last
visited Jan. 29, 2024).
15
Id.
16
Id.
17
Almutairi, et al., Economic Evaluation Patients with Advanced Unresectable Melanoma versus Economic Evaluation
Talimogene Laherparepvec Plus Ipilimumab Combination Therapy vs Ipilimumab Monotherapy in Patients With Advanced
Unresectable Melanoma, JAMA Dermatology, January 2019; 155(1):22-28, available at
https://pubmed.ncbi.nlm.nih.gov/30477000/ (last visited Jan. 29, 2024).
18
Id.
19
Section 20.121(3)(a), F.S. The Financial Services Commission, composed of the Governor, the Attorney General, the Chief
Financial Officer, and the Commissioner of Agriculture, serves as agency head of the Office of Insurance Regulation for
purposes of rulemaking. Further, the Financial Services Commission appoints the commissioner of the Office of Insurance
Regulation.
20
Section 624.418, F.S. BILL: CS/SB 56 Page 4
that holds a certificate of authority to transact insurance business in Florida.
21
As part of the
examination process, all persons being examined must make available to the OIR the accounts,
records, documents, files, information, assets, and matters in their possession or control that
relate to the subject of the examination.
22
The OIR is also authorized to conduct market conduct
examinations to determine compliance with applicable provisions of the Insurance Code.
23
The Agency for Health Care Administration (AHCA) regulates the quality of care by health
maintenance organizations (HMO) under part III of ch. 641, F.S. Before receiving a certificate of
authority from the OIR, an HMO must receive a Health Care Provider Certificate from AHCA.
24
As part of the certificate process used by the agency, an HMO must provide information to
demonstrate that the HMO has the ability to provide quality of care consistent with the prevailing
standards of care.
25
Patient Protection and Affordable Care Act
Essential Benefits
Under the Patient Protection and Affordable Care Act (PPACA),
26
all non-grandfathered health
plans in the non-group and small-group private health insurance markets must offer a core
package of health care services known as the essential health benefits (EHBs). While not
specifying the benefits within the EHB, the PPACA provides 10 categories of benefits and
services which must be covered and then required the Secretary of Health and Human Services
to further define the EHB.
27
The 10 EHB categories are:
Ambulatory patient services;
Emergency services;
Hospitalization;
Maternity and newborn care;
Mental health and substance use disorder services, including behavioral health treatment;
Prescription drugs;
Rehabilitation and habilitation services;
Laboratory services;
Preventive and wellness services and chronic disease management; and
Pediatric services, including oral and vision care.
The PPACA requires each state to select its own reference benchmark plan as its EHB
benchmark plan which all other health plans in the state use as a model. Beginning in 2020,
states could choose a new EHB plan using one of three options, including: selecting another’s
state benchmark plan; replacing one or more categories of EHB benefits; or selecting a set of
21
Section 624.316(1)(a), F.S.
22
Section 624.318(2), F.S.
23
Section 624.3161, F.S.
24
Section 641.21(1)(1), F.S.
25
Section 641.495, F.S.
26
Affordable Care Act, (March 23, 2010), P.L. 111-141, as amended.
27
45 CFR 156.100. et seq. BILL: CS/SB 56 Page 5
benefits that would become the State’s EHB benchmark plan.
28
Florida selected its EHB plan
before 2012 and has not modified that selection.
29
State Insurance Coverage Mandates
If a state elects to amend its benchmark plan later by imposing a statutory mandate to cover a
new service, the PPACA requires the state to pay for the additional costs of that mandate for the
entire industry.
30
According to a recent study, only two states have chosen to enhance their EHB
benchmark plans and have incurred the additional benefits penalty: Utah and Massachusetts.
31
Utah, for example, added a coverage mandate for applied behavioral analysis therapy for
individuals with autism in 2014 and subsequently implemented a state rule to allow the state to
reimburse the estimated five affected carriers for the autism claims with state funds.
32
Annually, the federal Centers for Medicare and Medicaid Services issues a Notice of Benefit and
Payment Parameters (NBPP) for the next plan year. The NBPP typically includes minor updates
to coverage standards, clarifications to prior policy statements, and announcements relating to
any major process changes. For the 2025 Plan Year which begins on January 1, 2025, the NBPP
proposes to codify that any new, additional benefits included in a state’s EHB plan would not be
considered an addition to the state’s EHB, and therefore not subject to the PPACA provision
requiring the state to defray the cost for the industry.
33
This change is part of a proposed rule
which has not yet been finalized, so it is unclear whether the PPACA state defrayal provision
will apply in future.
34
State Employee Health Plan
For state employees who participate in the state employee benefit program, the Department of
Management Services (DMS) through the Division of State Group Insurance (DSGI) administers
28
Centers for Medicare and Medicare Services, Marketplace & Private Insurance, Information on Essential Health Benefits
(EHB) Benchmark Plans, available at https://www.cms.gov/marketplace/resources/data/essential-health-benefits (last visited
Jan. 29, 2024).
29
Centers for Medicare and Medicaid Services, Information on Essential Health Benefits (EHB) Benchmark Plans, Florida
State Required Benefits, available at https://downloads.cms.gov/cciio/State%20Required%20Benefits_FL.pdf (last visited on
Jan. 29, 2024).
30
42 U.S.C. section 1803; See U.S. Preventive Services Task Force, Skin Cancer Prevention: Behavioral Counseling
(March 20, 2018) available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/skin-cancer-counseling
(last visited Jan. 29, 2024).
31
California Health Benefits Program, (CHBRP) (August 2023), Issue Brief: Essential Health Benefits: Exceeding EHBs and
the Defrayal Requirement, p.2. available at https://www.chbrp.org/sites/default/files/2023-08/EHB_Defrayal_FINAL.pdf
(last visited Jan. 29, 2024).
32
Utah Admin. Code R590-283 – Notice of Proposed Rule (November 1, 2019), available at DAR File No. 44181 (Rule
R590-283), 2019-22 Utah Bull. (11/15/2019)DAR File No. 44181 (Rule R590-283), 2019-22 Utah Bull. (11/15/2019) (last
visited Jan. 24, 2024).
33
Centers for Medicare and Medicaid Services, HHS Notice of Benefit and Payment Parameters for 2025 Proposed Rule
(Nov. 15, 2023), available at https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-
proposed-rule (last visited Jan. 29, 2024).
34
Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section
1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program, and Basic
Health Program, 88 Fed. Reg. 82510, 82553, 82630-82631, 82649, 82653-82654 (Nov. 24, 2023)(to be codified at
section 45 CFR 155.170 and 156.11), available at https://www.cms.gov/files/document/cms-9895-p-patient-protection-
final.pdf (last visited Jan. 29, 2024). BILL: CS/SB 56 Page 6
the state group health insurance program (Program).
35
The Program is a cafeteria plan managed
consistent with section 125 of the Internal Revenue Service Code.
36
To administer the program,
DSGI contracts with third party administrators for self-insured plans, a fully insured HMO, and a
pharmacy benefits manager for the state employees’ self-insured prescription drug program,
pursuant to s. 110.12315, F.S.
The state employee health plan contracts currently cover dermatology visits and skin cancer
screenings as a specialist office visit. Depending on the plan chosen by the employee, the
appropriate out of pocket cost or costs then applies for the specialist office visit.
37
Legislative Proposals for Mandated Health Benefit Coverage
Any person or organization proposing legislation which would mandate health coverage or the
offering of health coverage by an insurance carrier, health care service contractor, or health
maintenance organization (HMO) as a component of individual or group policies, must submit to
the Agency for Healthcare Administration (AHCA) and the legislative committees having
jurisdiction, a report which assesses the social and financial impacts of the proposed coverage.
38
Guidelines for assessing the impact of a proposed mandated or mandatorily offered health
coverage, to the extent that information is available, must include:
To what extent is the treatment or service generally used by a significant portion of the
population;
To what extent is the insurance coverage generally available;
If the insurance coverage is not generally available, to what extent does the lack of coverage
result in persons avoiding necessary health care treatment;
If the coverage is not generally available, to what extent does the lack of coverage result in
unreasonable financial hardship;
The level of public demand for the treatment or service;
The level of public demand for insurance coverage of the treatment or service;
The level of interest of collective bargaining agents in negotiating for the inclusion of this
coverage in group contracts;
To what extent will the coverage increase or decrease the cost of the treatment or service;
To what extent will the coverage increase the appropriate uses of the treatment or service;
To what extent will the mandated treatment or service be a substitute for a more expensive
treatment or service;
To what extent will the coverage increase or decrease the administrative expenses of
insurance companies and the premium and administrative expenses of policyholders; and
The impact of this coverage on the total cost of health care.
39
35
Section 110.123, F.S.
36
A section 125 cafeteria plan is a type of employer offered, flexible health insurance plan that provides employees a menu
of pre-tax and taxable qualified benefits to choose from, but employees must be offered at least one taxable benefit such as
cash, and one qualified benefit, such as a Health Savings Account.
37
Department of Management Services, Senate Bill 56 Agency Bill Analysis (Jan. 12, 2024) (on file with the Senate
Committee on Banking and Insurance).
38
Section 624.215(2), F.S.
39
Section 624.215(2)(a)-(l), F.S. BILL: CS/SB 56 Page 7
Proponents of the bill submitted a report to the Senate Committee on Banking and Insurance on
March 7, 2023, to comply with s. 624.215, F.S., addressing the guidelines for assessing the
impact of the proposed annual skin cancer screening mandated benefit, at no cost to the
insured.
40
III. Effect of Proposed Changes:
This bill amends s. 110.12303, F.S., to require, effective January 1, 2025, all contracted state
group health insurance plans and HMOs to cover and pay for annual skin cancer screenings
performed by a Florida licensed dermatologist. The bill prohibits a contracted state group health
insurance plan or HMO from imposing any cost-sharing requirement for the annual skin cancer
screening, including a deductible, copayment, coinsurance, or any other type of cost-sharing. The
provider conducting the screening must be a dermatologist licensed as a medical doctor under
ch. 458, F.S., or an osteopathic physician licensed under ch. 459, F.S., or an advanced practice
registered nurse licensed under chapter 464 F.S., who is under the supervision of a dermatologist
licensed under ch. 458 or ch. 459, F.S.
The bill requires payment for such annual skin cancer screenings to be consistent with a state
group health insurance plan’s or HMO’s payments for other preventive screenings, as defined by
the Current Procedural Terminology (CPT®) code set of the American Medical Association.
Lastly, the bill prohibits such insurers and HMOs from bundling a payment for skin cancer
screenings with any other procedure or service performed during the same or a subsequent office
visit as the screening.
The bill provides an effective date of July 1, 2024.
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None.
D. State Tax or Fee Increases:
None.
40
Florida Academy of Dermatology, Coverage for Skin Cancer Screenings, March 2023 (Report submitted pursuant to
s. 624.215, F.S.) (on file with the Senate Committee on Banking and Insurance). BILL: CS/SB 56 Page 8
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
The inclusion of coverage for skin cancer screenings with cost sharing restrictions may
positively impact physicians who likely will see an increased demand for their services as
well as collateral and ancillary medical supports such as laboratories and diagnostic
offices which will be called upon to process additional lab slips, biopsies, and scans.
Contracted state group health insurance plans and HMOs may need to update information
technology systems and processes to implement the provision of the bill.
C. Government Sector Impact:
The bill has a negative impact to state revenue and expenditures. The OIR has indicated it
may need to update its form review checklists and procedures to incorporate this new
requirement for the affected insurers;
41
such changes can be absorbed within existing
resources.
The DGSI within the DMS administers the Program. For the state employee group health
plan, the DMS has estimated an annual increase of $416,503 for no cost sharing liability
in the coverage of annual skin cancer screenings.
42
VI. Technical Deficiencies:
None.
VII. Related Issues:
According to the American Medical Association, CPT terminology is the most widely accepted
nomenclature used across the country to report medical, surgical, radiology, laboratory,
anesthesiology, genomic sequencing, evaluation and management services under public and
private health insurance programs. CPT codes offer doctors and health care professionals a
uniform language for coding medical services and procedures to streamline reporting, increase
accuracy and efficiency. The CPT Editorial Panel, responsible for maintaining and updating the
41
Office of Insurance Regulation, Senate Bill 56 Legislative Bill Analysis (Nov. 21, 2023) (on file with the Senate
Committee on Agriculture, Environment, and General Government).
42
Telephone call from Jake Holmgreen, Deputy Director of Legislative Affairs, Department of Management Services, to Niki
Davis, Legislative Analyst, Senate Committee on Agriculture, Environment, and General Government (Feb. 1, 2024). BILL: CS/SB 56 Page 9
CPT code set, meets three times a year to review applications for either new codes or revisions to
existing codes.
43
The DMS has indicated state group health insurance companies currently bundle payments based
on the primary codes and there is no CPT code for “skin cancer screenings.” As a result, manual
review of clinical records to input these changes and to update several systems and processes
may be required.
44
VIII. Statutes Affected:
This bill substantially amends section 110.12303 of the Florida Statutes.
IX. Additional Information:
A. Committee Substitute – Statement of Substantial Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS by Banking and Insurance on January 22, 2024:
The committee substitute removes the entire substance of the bill and amends
s. 110.12303, F.S., to provide that the provisions of the bill as filed apply only to the
contracted state group health insurance plans and HMOs.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.
43
American Medical Association, CPT® overview and code approval, https://www.ama-assn.org/practice-
management/cpt/cpt-overview-and-code-approval#:~:text=Code%20applications%20%26%20criteria-
,What%20is%20a%20CPT%C2%AE%20code%3F,reporting%2C%20increase%20accuracy%20and%20efficiency. (last
visited Jan. 29, 2024).
44
Id.