Relating to cost-sharing requirements for supplemental and diagnostic breast examinations

Description

House File 318 relates to cost-sharing requirements for supplemental and diagnostic breast examinations and does the following:

• Defines “cost-sharing.”
• Prohibits cost-sharing requirements for required coverage of supplemental and diagnostic breast examinations from being less favorable than cost-sharing requirements imposed for screening mammograms for policies, contracts, and plans providing for third-party payment or prepayment of health or medical expenses.
• Sets applicability for qualifying high-deductible health plans as defined in 26 U.S.C. 223 of the Internal Revenue Code (IRC) to apply only after the covered person satisfies the minimum deductible, except for preventive care as defined in the IRC.
• Sets applicability to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in the State on or after January 1, 2026.

Background

Under the current State of Iowa Plan designs, cost-sharing for preventive and screening mammograms, ultrasounds, and magnetic resonance imaging (MRI) is cost-free to the policyholder in nearly all cases, with mammograms making up the majority of the preventive imaging services covered. The same services for diagnostic purposes apply plan-specific cost-sharing, and shifting these cost-shares from plan members to the plan may result in an increase in claim spend.

The Bill is estimated to impact approximately 25.1% of the population of Iowa (806,000 individuals). This includes individual coverage, fully insured small and large employer groups, self-insured public employees, and the State of Iowa Plan.

Of the individuals not covered by the mandate, approximately 43.9% are covered by government-sponsored health insurance, 26.1% are covered by employer coverage that is governed by the federal Employee Retirement Income Security Act of 1974 (ERISA), and the remaining 4.9% are uninsured. Additional details are presented in Figure 1. Figure 1 — Population Covered by Insurance Plans Regulated by Iowa Law

Assumptions

• The Bill will increase the utilization of supplemental and diagnostic breast cancer imaging.
• Costs associated with early and increased detection cannot be determined.
• The costs to the State of Iowa Insurance Plan and the Board of Regents Insurance Plans may increase between 0.05% and 0.16%.

Fiscal Impact

House File 318 is estimated to increase annual costs to the State of Iowa Insurance Plan by an amount ranging between approximately $180,000 and $576,000 beginning in FY 2026. It is anticipated that the lower end of this range is more likely to occur. House File 318 is also estimated to increase the annual costs to the Board of Regents Insurance Plans by an amount ranging between approximately $263,000 and $842,000 beginning in FY 2026. It is anticipated that the lower end of this range is more likely to occur.

In total, House File 318 is estimated to increase annual costs to the State in an amount ranging between $443,000 and $1.4 million beginning in FY 2026. It is anticipated that the lower end of this range is more likely to occur.Type of Coverage

Iowa

Population

Percent of

Population

Total Population 2023 3,207,004 100.0%

Included in Mandate

Individual Coverage 117,298 3.7% Fully Insured Small Employer Group 133,147 4.2% Fully Insured Large Employer Group 288,902 9.0% Self-Insured Public Employees 215,000 6.7% State of Iowa Plan 51,316 1.6% Total 805,663 25.1%

Not Included in Mandate

Employer (self-insured + other types not listed) 838,458 26.1% Uninsured 156,600 4.9% Other Public (Military, Tricare, Veterans Affairs) 24,100 0.8% Medicare 671,902 21.0% Medicaid + Children’s Health Insurance Plan 710,281 22.1% Total 2,401,341 74.9% Sources: Iow a Insurance Division, Department of Insurance and Financial Services; Board of Regents; and Wellmark

Sources

• Iowa Insurance Division, Department of Insurance and Financial Services
• Board of Regents
• Wellmark