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/CS/SB 932
INTRODUCER: Appropriations Committee; Appropriations Committee on Agriculture, Environment,
and General Government; and Senator Berman and others
SUBJECT: Coverage for Diagnostic and Supplemental Breast Examinations
DATE: February 26, 2024
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Thomas Knudson BI Favorable
2. Davis Betta AEG Fav/CS
3. Davis Sadberry AP Fav/CS
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 932 prohibits the state group insurance program from imposing any cost-sharing
liability for diagnostic breast examinations and supplemental breast examinations in any contract
or plan for state employee health benefits that provides coverage for diagnostic breast
examinations or supplemental breast examinations. The prohibition is effective January 1, 2025,
consistent with the start of the new plan year.
The bill provides that if, under federal law, this prohibition would result in health savings
account ineligibility under s. 223 of the Internal Revenue Code, the prohibition applies only to
health savings account qualified high-deductible health plans with respect to the deductible of
such a plan after the person has satisfied the minimum deductible under such plan.
The bill has a significant, negative fiscal impact on the state. See Section V., Fiscal Impact
Statement.
The bill provides an effective date of January 1, 2025.
REVISED: BILL: CS/CS/SB 932 Page 2
II. Present Situation:
Background
Rates of breast cancer vary among different groups of people. Rates vary between women and
men and among people of different ethnicities and ages. Rates of breast cancer incidence (new
cases) and mortality (death) are much lower among men than among women. The American
Cancer Society made the following estimates regarding cancer among women in the U.S. during
2023:
297,790 new cases of invasive breast cancer (This includes new cases of primary breast
cancer, but not breast cancer recurrences);
55,720 new cases of ductal carcinoma in situ (DCIS), a non-invasive breast cancer; and
43,170 breast cancer deaths.
1
The estimates for men in the U.S. for 2023 were:
2,800 new cases of invasive breast cancer (This includes new cases of primary breast
cancers, but not breast cancer recurrences); and
530 breast cancer deaths.
2
Breast Cancer Screening
In Florida, a group, blanket, or franchise accident or health insurance policy issued, amended,
delivered, or renewed in this state must provide coverage for at least the following:
A baseline mammogram for any woman who is 35 years of age or older, but younger than 40
years of age.
A mammogram every two years for any woman who is 40 years of age or older, but younger
than 50 years of age, or more frequently based on the patient’s physician’s recommendation.
A mammogram every year for any woman who is 50 years of age or older.
One or more mammograms a year, based upon a physician’s recommendation, for any
woman who is at risk for breast cancer because of a personal or family history of breast
cancer, because of having a history of biopsy-proven benign breast disease, because of
having a mother, sister, or daughter who has or has had breast cancer, or because a woman
has not given birth before the age of 30.
3
Each such insurer must offer, for an appropriate additional premium, this same coverage without
such coverage being subject to the deductible or coinsurance provisions of the policy.
4
However, mammography is only the initial step in early detection and, by itself, unable to
diagnose cancer. A mammogram is an x-ray of the breast.
5
While screening mammograms are
routinely performed to detect breast cancer in women who have no apparent symptoms,
1
Cancer Facts & Figures, p. 4, American Cancer Society - https://www.cancer.org/cancer-facts-and-statistics (last visited
January 30, 2024).
2
Id.
3
Section 627.6613(1), F.S.
4
Section 627.6613(3), F.S.
5
What Is The Difference Between A Diagnostic Mammogram And A Screening Mammogram? National Breast Cancer
Foundation - https://www.nationalbreastcancer.org/diagnostic-mammogram (last visited January 30, 2024). BILL: CS/CS/SB 932 Page 3
diagnostic mammograms are used after suspicious results on a screening mammogram or after
some signs of breast cancer alert the physician to check the tissue.
6
If a mammogram shows something abnormal, early detection of breast cancer requires diagnostic
follow-up or additional supplemental imaging required to rule out breast cancer or confirm the
need for a biopsy.
7
An estimated 12-16 percent of women screened with modern digital
mammography require follow-up imaging.
8
Out-of-pocket costs are particularly burdensome on
those who have previously been diagnosed with breast cancer, as diagnostic tests are
recommended rather than traditional screening.
9
When breast cancer is detected early, the five-
year relative survival rate is ninety-nine percent.
10
Regulation of Insurance in Florida
The Office of Insurance Regulation (OIR) regulates specified insurance products, insurers and
other risk bearing entities in Florida.
11
As part of their regulatory oversight, the OIR may
suspend or revoke an insurer’s certificate of authority under certain conditions.
12
The OIR is
responsible for examining the affairs, transactions, accounts, records, and assets of each insurer
that holds a certificate of authority to transact insurance business in Florida.
13
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.
14
The OIR is also authorized to conduct market conduct
examinations to determine compliance with applicable provisions of the Insurance Code.
15
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.
16
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.
17
6
Id.
7
Breast Cancer Screening & Early Detection, Susan G. Komen Organization - https://www.komen.org/breast-
cancer/screening/ (last visited January 30, 2024).
8
Id.
9
Id.
10
Early Detection, National Breast Cancer Foundation - Breast Cancer Early Detection - National Breast Cancer Foundation
(last visited January 31, 2024).
11
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.
12
Section 624.418, F.S.
13
Section 624.316(1)(a), F.S.
14
Section 624.318(2), F.S.
15
Section 624.3161, F.S.
16
Section 641.21(1)(1), F.S.
17
Section 641.495, F.S. BILL: CS/CS/SB 932 Page 4
Patient Protection and Affordable Care Act
Essential Benefits
Under the Patient Protection and Affordable Care Act (PPACA),
18
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 the PPACA
does not specify the benefits within the EHB, it provides 10 categories of benefits and services
that must be covered and it requires the Secretary of Health and Human Services to further
define the EHB.
19
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.
Pediatric services, including oral and vision care.
The PPACA requires each state to select its own reference benchmark plan as its EHB
benchmark plan that 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 benefits
that would become the State’s EHB benchmark plan.
20
Florida selected its EHB plan before 2012
and has not modified that selection.
21
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.
22
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.
23
Utah, for example, added a coverage mandate for applied behavioral analysis therapy for
18
Affordable Care Act, (March 23, 2010), P.L.111-141, as amended.
19
45 CFR 156.100. et seq.
20
Centers for Medicare and Medicare Services, Marketplace – Essential Health Benefits, available at
https://www.cms.gov/marketplace/resources/data/essential-health-benefits (last reviewed January 30, 2024).
21
Centers for Medicare and Medicaid Services, Information on Essential Health Benefits (EHB) Benchmark Plans, Florida
State Required Benefits, available at https://downloads.cms.gov/ (last viewed on January 30, 2024).
22
42 U.S.C. section 1803 U.S. Preventive Services Task Force, Skin Cancer Prevention: Behavioral Counseling (March 20,
2018) available at Recommendation: Skin Cancer Prevention: Behavioral Counseling (last reviewed January 30, 2024).
23
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/ (last viewed January 30, 2024). BILL: CS/CS/SB 932 Page 5
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.
24
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.
25
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.
26
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
the state group health insurance program (Program).
27
The Program is a cafeteria plan managed
consistent with section 125 of the Internal Revenue Service Code.
28
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.
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 as a component of individual or group policies, must submit to the
AHCA and the legislative committees having jurisdiction a report which assesses the social and
financial impacts of the proposed coverage.
29
Guidelines for assessing the impact of a proposed
mandated or mandatorily offered health coverage, to the extent that information is available,
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?
24
Utah Admin. Code R590-283 – Notice of Proposed Rule (November 1, 2019), available at
https://rules.utah.gov/publicat/bulletin/2019/20191115/44181.htm (last viewed January 30, 2024).
25
CMS.GOV, HHS Notice of Benefit and Payment Parameters for 2025 Proposed Rule (November 15, 2023), available at
https://www.cms.gov/newsroom/fact-sheets/ (last viewed January 30, 2024).
26
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 (November 24, 2023)(to be codified at
section 45 CFR 155.170 and 156.11).
27
Section 110.123, F.S.
28
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.
29
Section 624.215(2), F.S. BILL: CS/CS/SB 932 Page 6
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?
The impact of this coverage on the total cost of health care.
30
To date, such a report has not been received by the Senate Committee on Banking and Insurance.
III. Effect of Proposed Changes:
Section 1 amends s. 110.123, F.S., to provide definitions of “Cost-sharing requirement,”
“Diagnostic breast examination,” and “Supplemental breast examination.”
Section 2 amends s. 110.12303, F.S., to prohibit the state group insurance program from
imposing on an enrollee any cost-sharing requirement (such as a deductible, copayment,
coinsurance, or any other cost-sharing) with respect to coverage for diagnostic breast
examinations and supplemental breast examinations in any contract or plan for state employee
health benefits that provides coverage for diagnostic breast examinations or supplemental breast
examinations. While current plans provide diagnostic breast examinations without cost sharing,
cost sharing for supplemental examinations among the current plans vary. The bill provides
parameters for what constitutes supplemental breast examinations, prohibiting cost sharing for
examinations that are:
Medically necessary and appropriate breast imaging examinations conducted in accordance
with the most recent applicable guidelines of the National Comprehensive Cancer Network,
which may include magnetic resonance imaging and ultrasounds and other types of
examinations;
Used when no abnormality is seen or suspected; and
Based on personal or family medical history or other increased risk factors.
The bill provides that if, under federal law, this prohibition would result in health savings
account ineligibility under s. 223 of the Internal Revenue Code, the prohibition applies only to
health savings account qualified high-deductible health plans with respect to the deductible of
such a plan after the person has satisfied the minimum deductible under such plan.
Section 3 provides that the bill takes effect January 1, 2025.
30
Section 624.215(2)(a)-(l), F.S. BILL: CS/CS/SB 932 Page 7
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.
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
The bill eliminates out-of-pocket costs for diagnostic and supplemental imaging for
breast examinations, which is anticipated to improve access to these tests and likely to
result in more patients receiving an earlier diagnosis. Early diagnosis increases the
likelihood of successful treatment, which may result in savings for health insurers and
HMOs.
C. Government Sector Impact:
The bill’s prohibition on out of pocket costs for diagnostic and supplemental breast
examinations has the potential to generate a higher insurance premium for the state group
health plan. Historically, the state has covered premium inflation in the Program with
General Revenue, rather than pass on premium increases to employees.
The Division of State Group Insurance within the Department of Management Services
(DMS) estimates the bill will have an estimated fiscal impact of $2.9 million annually in BILL: CS/CS/SB 932 Page 8
increased claim costs to state health plans due to the elimination of cost sharing and a
projected increase in utilization.
31
The DMS included the following fiscal impact breakout between the PPO and HMO
plans:
Due to the differences in cost sharing arrangements, the PPO plan will experience a
greater fiscal impact estimated at $2.7 million. The removal of cost sharing as it
relates to advanced imaging drives most of the estimated impact. The remaining
impact is due to an estimated 13-20 percent increase in utilization for both the under
age 40 population as well as the over age 40 population.
HMO impacts are estimated to be lower due to the limited cost share responsibility of
the standard HMO plan. Cumulative impacts for the HMO plans are estimated at
approximately $220,000. The removal of cost sharing as well as increased utilization
drives the estimated impact.
32
The bill does not appear to implicate the Patient Protection and Affordable Care Act, as it
is a cost-sharing bill only and does not mandate any new coverage or service or require
any additions to the benchmark plan. Florida’s EHB Benchmark Plan already includes
diagnostic imaging.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends the following sections of the Florida Statutes: 110.123 and
100.12303.
IX. Additional Information:
A. Committee Substitute – Statement of Substantial Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS/CS by Appropriations on February 21, 2024:
The committee substitute is a clarifying amendment to modify the definitions of terms
created in the bill. The definitions for the terms “diagnostic breast examination” and
“supplemental breast examination” are amended to specify the terms mean an imaging
examination of the breast, as determined in accordance with the most recent applicable
guidelines of the National Comprehensive Cancer Network.
31
See Department of Management Services, 2024 Agency Legislative Bill Analysis for HB 773 at 5 (Jan. 31, 2024) (on file
with the Senate Appropriations Committee on Agriculture, Environment, and General Government).
32
Id. BILL: CS/CS/SB 932 Page 9
CS by Appropriations Committee on Agriculture, Environment, and General
Government on February 13, 2024:
The committee substitute prohibits copayments and other cost sharing for supplemental
or diagnostic breast imaging within the state employee group health plan, for plans that
cover such services. The prohibition is effective January 1, 2025, consistent with the start
of the new plan year.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.