Colorectal Cancer Screening Act of 1995

Summary: Colorectal Cancer Screening Act of 1995 - Amends title XVIII (Medicare) of the Social Security Act to prescribe frequency and payment limits under Medicare part B (Supplementary Medical Insurance) for screening fecal-occult blood tests, flexible sigmoidoscopies, barium enemas, and other appropriate screening procedures for colorectal cancer, such as a colonoscopy.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Colorectal Cancer Screening Act of 
1995''.

SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREENING SERVICES.

    (a) In General.--Section 1834 of the Social Security Act (42 U.S.C. 
1395m) is amended by inserting after subsection (d) the following new 
subsection:
    ``(e) Frequency and Payment Limits for Colorectal Screening 
Procedures.--
            ``(1) Screening fecal-occult blood tests.--
                    ``(A) Payment limit.--In establishing fee schedules 
                under section 1833(h) with respect to screening fecal-
                occult blood tests provided for the purpose of early 
                detection of colon cancer, except as provided by the 
                Secretary under paragraph (3)(A), the payment amount 
                established for tests performed--
                            ``(i) in 1996 shall not exceed $5; and
                            ``(ii) in a subsequent year, shall not 
                        exceed the limit on the payment amount 
                        established under this subsection for such 
                        tests for the preceding year, adjusted by the 
                        applicable adjustment under section 1833(h) for 
                        tests performed in such year.
                    ``(B) Frequency limits.--Subject to revision by the 
                Secretary under paragraph (3)(B), no payment may be 
                made under this part for a screening fecal-occult blood 
                test provided to an individual for the purpose of early 
                detection of colon cancer if the test is performed--
                            ``(i) on an individual under 50 years of 
                        age; or
                            ``(ii) within the 11 months after a 
                        previous screening fecal-occult blood test.
            ``(2) Periodic colorectal screening procedures for 
        individuals not at high risk for colorectal cancer.--
                    ``(A) Payment amount.--The Secretary shall 
                establish a payment amount under section 1848 with 
                respect to periodic colorectal screening procedures 
                provided for the purpose of early detection of colon 
                cancer that is consistent with payment amounts under 
                such section for similar or related services, except 
                that such payment amount shall be established without 
                regard to subsection (a)(2)(A) of such section. The 
                Secretary shall establish a single payment amount for 
                periodic colorectal screening procedures, which shall 
                be based on the cost of a flexible sigmoidoscopy or 
                barium enema procedure, as the Secretary determines 
                appropriate.
                    ``(B) Frequency limits.--Subject to revision by the 
                Secretary under paragraph (4)(B), no payment may be 
                made under this part for a periodic colorectal 
                screening procedure provided to an individual for the 
                purpose of early detection of colon cancer if the 
                procedure is performed--
                            ``(i) on an individual under 50 years of 
                        age; or
                            ``(ii) within the 59 months after a 
                        previous periodic colorectal screening 
                        procedure.
                    ``(C) Periodic colorectal screening procedure 
                defined.--The term `periodic colorectal screening 
                procedure' means a flexible sigmoidoscopy, barium enema 
                screening procedure, or other screening procedure for 
                colorectal cancer, as determined by the Secretary.
            ``(3) Screening for individuals at high risk for colorectal 
        cancer.--
                    ``(A) Payment amount.--The Secretary shall 
                establish a payment amount under section 1848 with 
                respect to each eligible procedure for screening for 
                individuals at high risk for colorectal cancer (as 
                determined in accordance with criteria established by 
                the Secretary) provided for the purpose of early 
                detection of colon cancer that is consistent with 
                payment amounts under such section for similar or 
                related services, except that such payment amount shall 
                be established without regard to subsection (a)(2)(A) 
                of such section. The Secretary may establish a payment 
                amount for a barium enema procedure pursuant to this 
                paragraph that is different from the payment amount 
                established pursuant to paragraph (2) for a periodic 
                colorectal screening procedure for an individual not at 
                high risk for colorectal cancer so long as the payment 
                amount established pursuant to paragraph (2) is not 
                based on the cost of a barium enema procedure.
                    ``(B) Eligible procedures.--Procedures eligible for 
                payment under this part for screening for individuals 
                at high risk for colorectal cancer for the purpose of 
                early detection of colorectal cancer shall include a 
                screening colonoscopy, a barium enema screening 
                procedure, or other screening procedures for colorectal 
                cancer as the Secretary determines appropriate.
                    ``(C) Frequency limit.--Subject to revision by the 
                Secretary under paragraph (4)(B), no payment may be 
                made under this part for a screening procedure for 
                individuals at high risk for colorectal cancer provided 
                to an individual for the purpose of early detection of 
                colon cancer if the procedure is performed within the 
                23 months after a previous screening procedure.
                    ``(D) Factors considered in establishing criteria 
                for determining individuals at high risk.--In 
                establishing criteria for determining whether an 
                individual is at high risk for colorectal cancer for 
                purposes of this paragraph, the Secretary shall take 
                into consideration family history, prior experience of 
                cancer or precursor neoplastic polyps, a history of 
                chronic digestive disease condition (including 
                inflammatory bowel disease, Crohn's disease, or 
                ulcerative colitis), the presence of any appropriate 
                recognized gene markers for colorectal cancer and other 
                predisposing factors.
            ``(4) Reductions in payment limit and revision of 
        frequency.--
                    ``(A) Reductions in payment limit.--The Secretary 
                shall review from time to time the appropriateness of 
                the amount of the payment limit established for 
                screening fecal-occult blood tests under paragraph 
                (1)(A). The Secretary may, with respect to tests 
                performed in a year after 1998, reduce the amount of 
                such limit as it applies nationally or in any area to 
                the amount that the Secretary estimates is required to 
                assure that such tests of an appropriate quality are 
                readily and conveniently available during the year.
                    ``(B) Revision of frequency and determination of 
                eligible procedures.--
                            ``(i) Review.--The Secretary shall review 
                        periodically the appropriate frequency for 
                        performing screening fecal-occult blood tests, 
                        periodic colorectal screening procedures, and 
                        screening procedures for individuals at high 
                        risk for colorectal cancer based on age and 
                        such other factors as the Secretary believes to 
                        be pertinent, and shall review periodically the 
                        availability, effectiveness, and cost of 
                        screening procedures for colorectal cancer 
                        other than those specified in this section.
                            ``(ii) Revision of frequency and 
                        determination of eligible procedures.--The 
                        Secretary, taking into consideration the review 
                        made under clause (i), may revise from time to 
                        time the frequency with which such tests and 
                        procedures may be paid for under this 
                        subsection and may determine that additional 
                        screening procedures shall be considered to be 
                        `periodic colorectal screening procedures' or 
                        an eligible procedure for the screening of 
                        individuals at high risk for colorectal cancer, 
                        but no such revision shall apply to tests or 
                        procedures performed before January 1, 1999.
            ``(5) Limiting charges of nonparticipating physicians.--
                    ``(A) In general.--In the case of a periodic 
                colorectal screening procedure provided to an 
                individual for the purpose of early detection of colon 
                cancer or a screening provided to an individual at high 
                risk for colorectal cancer for the purpose of early 
                detection of colon cancer for which payment may be made 
                under this part, if a nonparticipating physician 
                provides the procedure to an individual enrolled under 
                this part, the physician may not charge the individual 
                more than the limiting charge (as defined in section 
                1848(g)(2)).
                    ``(B) Enforcement.--If a physician or supplier 
                knowing and willfully imposes a charge in violation of 
                subparagraph (A), the Secretary may apply sanctions 
                against such physician or supplier in accordance with 
                section 1842(j)(2).''.
    (b) Conforming Amendments.--(1) Paragraphs (1)(D) and (2)(D) of 
section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) are 
each amended by striking ``subsection (h)(1),'' and inserting 
``subsection (h)(1) or section 1834(e)(1),''.
    (2) Section 1823(h)(1)(A) of such Act (42 U.S.C. 1935l(h)(1)(A)) is 
amended by striking ``The Secretary'' and inserting ``Subject to 
paragraphs (1) and (3)(A) of section 1834(e), the Secretary''.
    (3) Clauses (i) and (ii) of section 1848(a)(2)(A) of such Act (42 
U.S.C. 1395w-4(a)(2)(A)) are each amended by striking ``a service'' and 
inserting ``a service (other than a periodic colorectal screening 
procedure provided to an individual for the purpose of early detection 
of colon cancer or an eligible screening procedure provided to an 
individual at high risk for colorectal cancer for the purpose of early 
detection of colon cancer)''.
    (4) Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended--
            (A) in paragraph (1)--
                    (i) in subparagraph (E), by striking ``and'' at the 
                end;
                    (ii) in subparagraph (F), by striking the semicolon 
                at the end and inserting ``, and''; and
                    (iii) by adding at the end the following new 
                subparagraph:
            ``(G) in the case of screening fecal-occult blood tests, 
        periodic colorectal screening procedures, and screening 
        procedures provided for the purpose of early detection of colon 
        cancer, which are performed more frequently than is covered 
        under section 1834(e);''; and
            (B) in paragraph (7), by striking ``paragraph (1)(B) or 
        under paragraph (1)(F)'' and inserting ``subparagraphs (B), 
        (F), or (G) of paragraph (1)''.

SEC. 3. EFFECTIVE DATE.

    The amendments made by section 2 shall apply to services furnished 
on or after January 1, 1996.