I

104TH CONGRESS

1ST SESSION H. R. 1046

To amend title XVIII of the Social Security Act to provide for coverage

of periodic colorectal screening services under part B of the medicare program.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 24, 1995

Mr. HASTINGS of Florida, introduced the following bill; which was referred to

the Committee on Commerce and, in addition, to the Committee on Ways

and Means, for a period to be subsequently determined by the Speaker,

in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title XVIII of the Social Security Act to provide

for coverage of periodic colorectal screening services

under part B of the medicare program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Colorectal Cancer

5 Screening Act of 1995’’.
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1 SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREEN2 ING SERVICES.

3 (a) IN GENERAL.—Section 1834 of the Social Secu4 rity Act (42 U.S.C. 1395m) is amended by inserting after

5 subsection (d) the following new subsection:

6 ‘‘(e) FREQUENCY AND PAYMENT LIMITS FOR

7 COLORECTAL SCREENING PROCEDURES.—

8 ‘‘(1) SCREENING FECAL-OCCULT BLOOD

9 TESTS.—

10 ‘‘(A) PAYMENT LIMIT.—In establishing fee

11 schedules under section 1833(h) with respect to

12 screening fecal-occult blood tests provided for

13 the purpose of early detection of colon cancer,

14 except as provided by the Secretary under para15 graph (3)(A), the payment amount established

16 for tests performed—

17 ‘‘(i) in 1998 shall not exceed $5; and

18 ‘‘(ii) in a subsequent year, shall not

19 exceed the limit on the payment amount

20 established under this subsection for such

21 tests for the preceding year, adjusted by

22 the applicable adjustment under section

23 1833(h) for tests performed in such year.

24 ‘‘(B) LIMITING COVERAGE FOR NON-EL25 DERLY TO HIGH-RISK INDIVIDUALS.—No pay26 ment may be made under this part for a screen-
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1 ing fecal-occult blood test provided for the pur2 pose of early detection of colon cancer to an in3 dividual who is under 65 years of age unless the

4 individual is at high risk for colorectal cancer

5 (as determined in accordance with criteria es6 tablished by the Secretary).

7 ‘‘(C) FREQUENCY LIMITS.—Subject to re8 vision by the Secretary under paragraph (3)(B),

9 no payment may be made under this part for

10 a screening fecal-occult blood test provided to

11 an individual for the purpose of early detection

12 of colon cancer if the test is performed—

13 ‘‘(i) in the case of an individual under

14 65 years of age, more frequently than is

15 provided in a periodicity schedule estab16 lished by the Secretary for purposes of this

17 subparagraph; or

18 ‘‘(ii) in the case of any other individ19 ual, within the 11 months after a previous

20 screening fecal-occult blood test.

21 ‘‘(2) PERIODIC COLORECTAL SCREENING PRO22 CEDURES FOR INDIVIDUALS NOT AT HIGH RISK FOR

23 COLORECTAL CANCER.—

24 ‘‘(A) PAYMENT AMOUNT.—The Secretary

25 shall establish a payment amount under section
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1 1848 with respect to periodic colorectal screen2 ing procedures provided for the purpose of early

3 detection of colon cancer that is consistent with

4 payment amounts under such section for similar

5 or related services, except that such payment

6 amount shall be established without regard to

7 subsection (a)(2)(A) of such section. The Sec8 retary shall establish a single payment amount

9 for periodic colorectal screening procedures,

10 which shall be based on the cost of a flexible

11 sigmoidoscopy or barium enema procedure, as

12 the Secretary determines appropriate.

13 ‘‘(B) LIMITING COVERAGE FOR NON-EL14 DERLY TO HIGH-RISK INDIVIDUALS.—No pay15 ment may be made under this part for a peri16 odic colorectal screening procedure provided for

17 the purpose of early detection of colon cancer to

18 an individual who is under 65 years of age un19 less the individual is at high risk for colorectal

20 cancer (as determined in accordance with cri21 teria established by the Secretary).

22 ‘‘(C) FREQUENCY LIMITS.—Subject to re23 vision by the Secretary under paragraph (4)(B),

24 no payment may be made under this part for

25 a periodic colorectal screening procedure pro-
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1 vided to an individual for the purpose of early

2 detection of colon cancer if the procedure is

3 performed—

4 ‘‘(i) in the case of an individual under

5 65 years of age, more frequently than is

6 provided in a periodicity schedule estab7 lished by the Secretary for purposes of this

8 subparagraph; or

9 ‘‘(ii) in the case of any other individ10 ual, within the 59 months after a previous

11 periodic colorectal screening procedure.

12 ‘‘(D) PERIODIC COLORECTAL SCREENING

13 PROCEDURE DEFINED.—The term ‘periodic

14 colorectal screening procedure’ means a flexible

15 sigmoidoscopy, barium enema screening proce16 dure, or other screening procedure for colorectal

17 cancer, as determined by the Secretary.

18 ‘‘(3) SCREENING FOR INDIVIDUALS AT HIGH

19 RISK FOR COLORECTAL CANCER.—

20 ‘‘(A) PAYMENT AMOUNT.—The Secretary

21 shall establish a payment amount under section

22 1848 with respect to each eligible procedure for

23 screening for individuals at high risk for

24 colorectal cancer (as determined in accordance

25 with criteria established by the Secretary) pro-
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1 vided for the purpose of early detection of colon

2 cancer that is consistent with payment amounts

3 under such section for similar or related serv4 ices, except that such payment amount shall be

5 established without regard to subsection

6 (a)(2)(A) of such section. The Secretary may

7 establish a payment amount for a barium

8 enema procedure pursuant to this paragraph

9 that is different from the payment amount es10 tablished pursuant to paragraph (2) for a peri11 odic colorectal screening procedure for an indi12 vidual not a high risk for colorectal cancer so

13 long as the payment amount established pursu14 ant to paragraph (2) is not based on the cost

15 of a barium enema procedure.

16 ‘‘(B) ELIGIBLE PROCEDURES.—Procedures

17 eligible for payment under this part for screen18 ing for individuals at high risk for colorectal

19 cancer for the purpose of early detection of

20 colorectal cancer shall include a screening

21 colonoscopy, a barium enema screening proce22 dure, or other screening procedures for

23 colorectal cancer as the Secretary determines

24 appropriate.
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1 ‘‘(C) FREQUENCY LIMIT.—Subject to revi2 sion by the Secretary under paragraph (4)(B),

3 no payment may be made under this part for

4 a screening procedure for individuals at high

5 risk for colorectal cancer provided to an individ6 ual for the purpose of early detection of colon

7 cancer if the procedure is performed within the

8 47 months after a previous screening procedure.

9 ‘‘(D) FACTORS CONSIDERED IN ESTAB10 LISHING CRITERIA FOR DETERMINING INDIVID11 UALS AT HIGH RISK.—In establishing criteria

12 for determining whether an individual is at high

13 risk for colorectal cancer for purposes of this

14 paragraph, the Secretary shall take into consid15 eration family history, prior experience of can16 cer, a history of chronic digestive disease condi17 tion, and the presence of any appropriate recog18 nized gene markers for colorectal cancer.

19 ‘‘(4) REDUCTIONS IN PAYMENT LIMIT AND RE20 VISION OF FREQUENCY.—

21 ‘‘(A) REDUCTIONS IN PAYMENT LIMIT.—

22 The Secretary shall review from time to time

23 the appropriateness of the amount of the pay24 ment limit established for screening fecal-occult

25 blood tests under paragraph (1)(A). The Sec-
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1 retary may, with respect to tests performed in

2 a year after 2002, reduce the amount of such

3 limit as it applies nationally or in any area to

4 the amount that the Secretary estimates is re5 quired to assure that such tests of an appro6 priate quality are readily and conveniently

7 available during the year.

8 ‘‘(B) REVISION OF FREQUENCY AND DE9 TERMINATION OF ELIGIBLE PROCEDURES.—

10 ‘‘(i) REVIEW.—The Secretary shall re11 view periodically the appropriate frequency

12 for performing screening fecal-occult blood

13 tests, periodic colorectal screening proce14 dures, and screening procedures for indi15 viduals at high risk for colorectal cancer

16 based on age and such other factors as the

17 Secretary believes to be pertinent, and

18 shall review periodically the availability, ef19 fectiveness, and cost of screening proce20 dures for colorectal cancer other than

21 those specified in this section.

22 ‘‘(ii) REVISION OF FREQUENCY AND

23 DETERMINATION OF ELIGIBLE PROCE24 DURES.—The Secretary, taking into con25 sideration the review made under clause
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1 (i), may revise from time to time the fre2 quency with which such tests and proce3 dures may be paid for under this sub4 section and may determine that additional

5 screening procedures shall be considered to

6 be ‘periodic colorectal screening proce7 dures’ or an eligible procedure for the

8 screening of individuals at high risk for

9 colorectal cancer, but no such revision shall

10 apply to tests or procedures performed be11 fore January 1, 2002.

12 ‘‘(5) LIMITING CHARGES OF NONPARTICIPATING

13 PHYSICIANS.—

14 ‘‘(A) IN GENERAL.—In the case of a peri15 odic colorectal screening procedure provided to

16 an individual for the purpose of early detection

17 of colon cancer or a screening provided to an

18 individual at high risk for colorectal cancer for

19 the purpose of early detection of colon cancer

20 for which payment may be made under this

21 part, if a nonparticipating physician provides

22 the procedure to an individual enrolled under

23 this part, the physician may not charge the in24 dividual more than the limiting charge (as de25 fined in section 1848(g)(2)).
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1 ‘‘(B) ENFORCEMENT.—If a physician or

2 supplier knowing and willfully imposes a charge

3 in violation of subparagraph (A), the Secretary

4 may apply sanctions against such physician or

5 supplier in accordance with section

6 1842(j)(2).’’.

7 (b) CONFORMING AMENDMENTS.—(1) Paragraphs

8 (1)(D) and (2)(D) of section 1833(a) of the Social Secu9 rity Act (42 U.S.C. 1395l(a)) are each amended by strik10 ing ‘‘subsection (h)(1),’’ and inserting ‘‘subsection (h)(1)

11 or section 1834(e)(1),’’.

12 (2) Section 1833(h)(1)(A) of such Act (42 U.S.C.

13 1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’

14 and inserting ‘‘Subject to paragraphs (1) and (3)(A) of

15 section 1834(e), the Secretary’’.

16 (3) Clauses (i) and (ii) of section 1848(a)(2)(A) of

17 such Act (42 U.S.C. 1395w–4(a)(2)(A)) are each amended

18 by striking ‘‘a service’’ and inserting ‘‘a service (other

19 than a periodic colorectal screening procedure provided to

20 an individual for the purpose of early detection of colon

21 cancer or an eligible screening procedure provided to an

22 individual at high risk for colorectal cancer for the purpose

23 of early detection of colon cancer)’’.

24 (4) Section 1862(a) of such Act (42 U.S.C. 1395y(a))

25 is amended—
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1 (A) in paragraph (1)—

2 (i) in subparagraph (E), by striking ‘‘and’’

3 at the end;

4 (ii) in subparagraph (F), by striking the

5 semicolon at the end and inserting ‘‘, and’’; and

6 (iii) by adding at the end the following new

7 subparagraph:

8 ‘‘(G) in the case of screening fecal-occult blood

9 tests, periodic colorectal screening procedures, and

10 screening procedures provided for the purpose of

11 early detection of colon cancer, which are performed

12 more frequently than is covered under section

13 1834(e);’’; and

14 (B) in paragraph (7), by striking ‘‘paragraph

15 (1)(B) or under paragraph (1)(F)’’ and inserting

16 ‘‘subparagraphs (B), (F), or (G) of paragraph (1)’’.

17 SEC. 3. EFFECTIVE DATE.

18 The amendments made by section 2 shall apply to

19 services furnished on or after January 1, 1996.

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