How Does Florida SB 158 Change Breast Imaging Billing Laws? | Medical Billing Attorneys

How Florida Senate Bill 158 Changes Compliance and Reimbursement for Breast Imaging: A Legal Analysis

In the complex landscape of healthcare reimbursement and compliance, few things are as critical as staying ahead of legislative changes that alter payer obligations and patient cost-sharing structures. For medical billing attorneys, compliance officers, and healthcare administrators, the passage of Florida Senate Bill 158 represents a significant shift in the regulatory framework governing diagnostic imaging.

Effective January 1, 2026, this legislation fundamentally changes how the state group insurance program covers diagnostic and supplemental breast examinations[1]. As experienced attorneys who have spent decades representing healthcare providers in reimbursement disputes, audits, and regulatory compliance, we understand that a change in cost-sharing statutes is never just a billing update. It is a legal pivot that requires a comprehensive review of internal policies to avoid compliance pitfalls.

At Johnson Pope, our Health Care Group closely monitors these developments to ensure our clients are prepared. If you are navigating the complexities of healthcare compliance or reimbursement disputes, contact Johnson Pope today to safeguard your practice against regulatory risks.

What Is Florida Senate Bill 158 and When Does It Take Effect?

Florida Senate Bill 158 (SB 158) was signed into law by Governor Ron DeSantis on May 20, 2025. The law specifically addresses coverage requirements for diagnostic and supplemental breast examinations within the state group insurance program.

The primary legal operative of the bill is the prohibition of cost-sharing requirements for specific breast imaging procedures. Historically, while screening mammograms have often been covered without cost-sharing under preventive care mandates, follow-up diagnostic imaging often subjected patients to deductibles, coinsurance, and copayments. SB 158 removes these financial barriers for enrollees in the state group insurance program.

How Does SB 158 Define Diagnostic and Supplemental Breast Examinations?

For legal professionals and billing specialists, the statutory definitions found in the bill are the most critical components for accurate coding and compliance. The text of SB 158 amends Section 110.123 of the Florida Statutes to provide precise legal definitions that align with clinical guidelines.[2]

The statute defines a “Diagnostic breast examination” as a medically necessary and appropriate imaging examination of the breast used to evaluate an abnormality that is seen or suspected during a screening examination for breast cancer. The law specifies that this determination must be made in accordance with the most recent applicable guidelines of the National Comprehensive Cancer Network (NCCN). Notably, the definition explicitly includes, but is not limited to, examinations using diagnostic mammography, breast magnetic resonance imaging (MRI), or breast ultrasound.[3]

Furthermore, the law introduces a distinct definition for a “Supplemental breast examination”. This is defined as a medically necessary and appropriate imaging examination of the breast conducted in accordance with NCCN guidelines that is used to screen for breast cancer when there is no abnormality seen or suspected. This applies specifically when the examination is based on personal or family medical history or additional factors that may increase the person’s risk of breast cancer.[4]

These definitions are vital for medical billing attorneys to understand because they link legal coverage mandates directly to clinical guidelines. If a provider bills for a service that fits these statutory definitions and, under the state group plan, attempts to collect a co-pay or deductible, they could now be in violation of the statute.

Does your compliance team need assistance interpreting statutory definitions for billing protocols? Contact the Johnson Pope Health Care Group for a comprehensive review of your billing practices.

Which Health Plans Are Subject to the New SB 158 Cost-Sharing Prohibitions?

It is essential for providers to understand the scope of this legislation to avoid over-applying or under-applying its provisions. SB 158 specifically amends statutes governing the “state group insurance program”.

The text of the bill prohibits the state group insurance program from imposing any cost-sharing requirement upon an enrollee with respect to coverage for diagnostic breast examinations or supplemental breast examinations. This affects plans covering state employees and potentially other groups falling under this specific statutory umbrella.

While this specific bill applies to the state group insurance program, as medical billing lawyers with decades of experience, we are aware that such legislation often sets a standard that may be mirrored in other sectors or future legislation. For example, similar measures have been enacted in states like Arkansas, Colorado, and Texas, indicating a broader national trend toward eliminating cost-sharing for these procedures.[5] However, for the purposes of strict legal compliance with Florida SB 158, the prohibition applies to the state group insurance entity.

Distinguishing between patients covered by the state group insurance program and those covered by private commercial carriers or self-funded ERISA plans is critical. Applying the cost-sharing waiver universally without verifying the payer could lead to revenue loss, while failing to apply it to the correct population could lead to compliance violations.

How Does SB 158 Impact “Cost-Sharing Requirements” and Patient Billing?

The statute provides a concrete definition of prohibited billing practices. Under the amended Section 110.123(2)(a), “Cost-sharing requirement” is defined to mean an insured’s deductible, coinsurance, copayment, or similar out-of-pocket expense.[6]

From a legal and billing perspective, this constitutes a total ban on collecting these specific funds from the patient for qualifying services. If a healthcare provider performs a medically necessary breast ultrasound for a patient with dense breast tissue (a supplemental exam) who is insured by the state group program, the provider must accept the insurance reimbursement as payment in full regarding the patient’s liability.

This has significant implications for “balance billing” protocols. Billing software must be programmed to recognize these specific CPT codes when associated with the state group insurance payer ID to ensure that no patient balance is generated for the deductible or coinsurance.

As dedicated medical billing attorneys, we are paying close attention to the intersection of this law with other Florida statutes regarding overpayments. For instance, recent legislative updates, such as SB 1808, require healthcare practitioners to refund any overpayment made by a patient no later than 30 days after determining that the patient made an overpayment. If a provider mistakenly collects a copayment for a diagnostic MRI covered under SB 158, they face a strict timeline to refund that money or potentially face disciplinary action or penalties.

Ensure your practice avoids costly overpayment disputes. Let Johnson Pope’s medical billing attorneys guide you through the complexities of Florida’s refund and overpayment laws.

How Does the High Deductible Health Plan (HDHP) Exception Work?

One of the most technically complex aspects of SB 158 is its interaction with federal tax law regarding Health Savings Accounts (HSAs). For providers, understanding this “safe harbor” provision is essential to prevent misinterpretation of the law.

The statute includes a specific exception to ensure compliance with the Internal Revenue Code. The law states that if the application of the no-cost-sharing provision would result in Health Savings Account (HSA) ineligibility under Section 223 of the Internal Revenue Code, the prohibition only applies strictly under specific conditions.[7]

Specifically, for HSA-qualified High-Deductible Health Plans (HDHPs), the prohibition on cost-sharing applies only after the person has satisfied the minimum deductible required under federal law. The exception to this is if the items or services are deemed “preventive care” pursuant to Section 223(c)(2)(C) of the Internal Revenue Code.[8]

This nuance is critical. If a diagnostic exam is not classified as “preventive” under federal IRS guidelines, the state law cannot force the plan to waive the deductible before the federal minimum is met without disqualifying the plan as an HSA-compatible vehicle. Therefore, billing departments must be able to distinguish between a standard plan where the waiver is immediate and an HDHP where the waiver applies only after the federal minimum deductible is satisfied.

What Are the Risks of Non-Compliance for Healthcare Providers?

The regulatory environment for healthcare providers in Florida is increasingly scrutinized. Non-compliance with billing statutes like SB 158 can expose practices to various legal risks, ranging from administrative penalties to litigation.

Our Health Care Defense Group at Johnson Pope regularly represents clients in matters related to overpayment and improper payments. Ignoring the effective date of January 1, 2026, or misinterpreting the definition of “diagnostic” versus “screening” exams, can significantly increase audit risk.

If a provider routinely collects deductibles for services that are statutorily exempt from cost-sharing, this could be viewed as a systemic billing error or, in worst-case scenarios, a deceptive practice. Furthermore, accurate implementation of these rules is required to maintain good standing with payer networks. State group insurance programs likely will strictly enforce these provisions, and providers found in violation may face recoupment demands or exclusion from the network.

Additionally, because the law ties the definitions of diagnostic and supplemental exams to NCCN guidelines, providers must ensure their clinical documentation supports the medical necessity criteria outlined in those guidelines. If the medical record does not substantiate the abnormality or risk factors required to classify the exam as “diagnostic” or “supplemental,” the reimbursement protections of SB 158 might not apply, leading to claim denials or valid patient billing liability that was otherwise thought to be waived.

Don’t wait for an audit to verify your compliance. Contact Johnson Pope for a proactive audit of your billing procedures and compliance plans.

Why Should Healthcare Providers Review Payer Contracts and Fee Schedules?

While SB 158 is a state statute, its execution relies heavily on the contractual relationship between the provider and the payer. The elimination of patient cost-sharing means that the entire allowable fee must be reimbursed by the payer.

As experienced medical billing attorneys, we regularly advise clients to review their fee schedules and managed care contracts associated with the state group insurance program. It is vital to verify that the payer’s reimbursement rates are sufficient to cover the cost of the service when the patient contribution is removed. While the law mandates coverage, it does not necessarily dictate the total reimbursement amount, only the allocation of liability between the payer and the patient.

Providers should monitor their Explanation of Benefits (EOBs) and Remittance Advice closely starting in January 2026. If the payer continues to assign a deductible to the patient for a qualifying diagnostic breast exam, the provider must have a mechanism to appeal that adjudication based on the statutory authority of SB 158.

What Steps Should Legal and Billing Teams Take Now to Comply With SB 158?

Preparation is the best defense against regulatory liability. If your practice or business has not done so already, your billing teams should undertake a systematic review of their operations.

First, identify the specific payer IDs associated with the Florida state group insurance program within your practice management system. These are the claims that will require special handling logic to prevent the automated assignment of patient balances for diagnostic imaging.

Second, educate clinical staff on the specific documentation required to satisfy the NCCN guideline definitions cited in the statute. The difference between a “screening” code and a “diagnostic” code often comes down to the specificity of the findings recorded by the radiologist or ordering physician.

Third, update patient financial responsibility waivers and intake forms. Patients under the state group plan should be informed that their diagnostic imaging may be covered at no cost, but transparency regarding the HDHP/HSA exception is necessary to manage expectations and avoid disputes if they have not met their federal minimum deductible.

Finally, establish a protocol for handling overpayments. With the concurrent pressure of laws like SB 1808, which mandates refunds within 30 days of discovery, your back-office team must be agile in identifying and returning any copays that were inadvertently collected for covered services.

Don’t Incur Potential Liability By Ignoring SB 158. Call Johnson Pope Today to Schedule A Consultation With An Experienced Medical Billing Lawyer.

Florida Senate Bill 158 represents a positive step toward removing financial barriers to healthcare for state employees, but for the healthcare providers serving them, it presents a strict set of new operational rules. Accurate interpretation of “diagnostic” and “supplemental” definitions, careful adherence to HSA exceptions, and precise billing execution are mandatory to remain compliant.

The healthcare attorneys at Johnson Pope have decades of collective experience representing healthcare businesses in matters of privacy, security, and billing compliance. We understand the challenges of complying with ever-changing laws and work with clients to adopt procedures that meet these required standards.

Protect your practice and ensure full compliance. Call Johnson Pope today to schedule a consultation with our experienced medical billing attorneys.

[1] Animal cruelty, breast exams, new Florida laws taking effect on Jan. 1, Tallahassee Democrat (last visited Jan. 2026), https://www.tallahassee.com/story/news/2025/12/31/animal-cruelty-breast-exam-insurance-new-florida-laws/87943624007/; Fla. S.B. 158 (2025).

[2] Fla. S.B. 158 (2025).

[3] Id.

[4] Id.

[5] Seven States Enact Breast Health Legislation, American College of Radiology (June 25, 2025), https://www.acr.org/News-and-Publications/seven-states-enact-breast-health-legislation.

[6] Fla. S.B. 158 (2025).

[7] Id.

[8] Id.