I

104TH CONGRESS

1ST SESSION H. R. 2777

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

coverage of preventive benefits under part B of the medicare program.

IN THE HOUSE OF REPRESENTATIVES

DECEMBER 13, 1995

Mr. CARDIN 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 expanded coverage of preventive benefits 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 ‘‘Medicare Preventive

5 Benefits Improvement Act of 1995’’.

6 SEC. 2. SCREENING MAMMOGRAPHY.

7 (a) PROVIDING ANNUAL SCREENING MAMMOGRAPHY

8 FOR WOMEN OVER AGE 49.—Section 1834(c)(2)(A) of
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1 the Social Security Act (42 U.S.C. 1395m(c)(2)(A)) is

2 amended—

3 (1) in clause (iv), by striking ‘‘but under 65

4 years of age,’’; and

5 (2) by striking clause (v).

6 (b) WAIVER OF DEDUCTIBLE.—The first sentence of

7 section 1833(b) of such Act (42 U.S.C. 1395l(b)) is

8 amended—

9 (1) by striking ‘‘and (4)’’ and inserting ‘‘(4)’’;

10 and

11 (2) by striking the period at the end and insert12 ing the following: ‘‘, and (5) such deductible shall

13 not apply with respect to screening mammography

14 (as described in section 1861(jj)).’’.

15 (c) CONFORMING AMENDMENT.—Section

16 1834(c)(1)(C) of such Act (42 U.S.C. 1395m(c)(1)(C)) is

17 amended by striking ‘‘, subject to the deductible estab18 lished under section 1833(b),’’.

19 SEC. 3. SCREENING PAP SMEAR AND PELVIC EXAMS.

20 (a) COVERAGE OF PELVIC EXAM; INCREASING FRE21 QUENCY OF COVERAGE OF PAP SMEAR.—Section

22 1861(nn) of the Social Security Act (42 U.S.C.

23 1395x(nn)) is amended—

24 (1) in the heading, by striking ‘‘Smear’’ and in25 serting ‘‘Smear; Screening Pelvic Exam’’;
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1 (2) by striking ‘‘(nn)’’ and inserting ‘‘(nn)(1)’’;

2 (3) by striking ‘‘3 years’’ and all that follows

3 and inserting ‘‘3 years, or during the preceding year

4 in the case of a woman described in paragraph (3).’’;

5 and

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

7 paragraphs:

8 ‘‘(2) The term ‘screening pelvic exam’ means a pelvic

9 examination provided to a woman if the woman involved

10 has not had such an examination during the preceding 3

11 years, or during the preceding year in the case of a woman

12 described in paragraph (3), and includes a clinical breast

13 examination.

14 ‘‘(3) A woman described in this paragraph is a

15 woman who—

16 ‘‘(A) is of childbearing age and has not had a

17 test described in this subsection during each of the

18 preceding 3 years that did not indicate the presence

19 of cervical cancer; or

20 ‘‘(B) is at high risk of developing cervical can21 cer (as determined pursuant to factors identified by

22 the Secretary).’’.

23 (b) WAIVER OF DEDUCTIBLE.—The first sentence of

24 section 1833(b) of such Act (42 U.S.C. 1395l(b)), as

25 amended by section 2(b), is amended—
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1 (1) by striking ‘‘and (5)’’ and inserting ‘‘(5)’’;

2 and

3 (2) by striking the period at the end and insert4 ing the following: ‘‘, and (6) such deductible shall

5 not apply with respect to screening pap smear and

6 screening pelvic exam (as described in section

7 1861(nn)).’’.

8 (c) CONFORMING AMENDMENTS.—(1) Section

9 1861(s)(14) of such Act (42 U.S.C. 1395x(s)(14)) is

10 amended by inserting ‘‘and screening pelvic exam’’ after

11 ‘‘screening pap smear’’.

12 (2) Section 1862(a)(1)(F) of such Act (42 U.S.C.

13 1395y(a)(1)(F)) is amended by inserting ‘‘and screening

14 pelvic exam’’ after ‘‘screening pap smear’’.

15 SEC. 4. COVERAGE OF COLORECTAL SCREENING.

16 (a) IN GENERAL.—

17 (1) COVERAGE.—Section 1861(s)(2) of the So18 cial Security Act (42 U.S.C. 1395x(s)(2)) is amend19 ed—

20 (A) by striking ‘‘and’’ at the end of sub21 paragraph (N) and subparagraph (O); and

22 (B) by inserting after subparagraph (O)

23 the following new subparagraph:

24 ‘‘(P) colorectal cancer screening tests (as de25 fined in subsection (oo)); and’’.
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1 (2) TESTS DESCRIBED.—Section 1861 of such

2 Act (42 U.S.C. 1395x) is amended by adding at the

3 end the following new subsection:

4 ‘‘Colorectal Cancer Screening Tests

5 ‘‘(oo)(1) The term ‘colorectal cancer screening test’

6 means any of the following procedures furnished to an in7 dividual for the purpose of early detection of colorectal

8 cancer:

9 ‘‘(A) Screening fecal-occult blood test.

10 ‘‘(B) Screening flexible sigmoidoscopy.

11 ‘‘(C) In the case of an individual at high risk

12 for colorectal cancer, screening colonoscopy.

13 ‘‘(D) Screening barium enema, if found by the

14 Secretary to be an appropriate alternative to screen15 ing flexible sigmoidoscopy under subparagraph (B)

16 or screening colonoscopy under subparagraph (C).

17 ‘‘(E) For years beginning after 2002, such

18 other procedures as the Secretary finds appropriate

19 for the purpose of early detection of colorectal can20 cer, taking into account changes in technology and

21 standards of medical practice, availability, effective22 ness, costs, and such other factors as the Secretary

23 considers appropriate.

24 ‘‘(2) In paragraph (1)(C), an ‘individual at high risk

25 for colorectal cancer’ is an individual who, because of fam-
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1 ily history, prior experience of cancer or precursor neo2 plastic polyps, a history of chronic digestive disease condi3 tion (including inflammatory bowel disease, Crohn’s Dis4 ease, or ulcerative colitis), the presence of any appropriate

5 recognized gene markers for colorectal cancer, or other

6 predisposing factors, faces a high risk for colorectal can7 cer.’’.

8 (3) DEADLINE FOR DECISION ON COVERAGE OF

9 SCREENING BARIUM ENEMA.—Not later than 2

10 years after the date of the enactment of this Act, the

11 Secretary of Health and Human Services shall issue

12 and publish a determination on the treatment of

13 screening barium enema as a colorectal cancer

14 screening test under section 1861(oo) of the Social

15 Security Act (as added by paragraph (2)) as an al16 ternative procedure to a screening flexible

17 sigmoidoscopy or screening colonoscopy.

18 (b) FREQUENCY AND PAYMENT LIMITS.—

19 (1) IN GENERAL.—Section 1834 of the Social

20 Security Act (42 U.S.C. 1395m) is amended by in21 serting after subsection (c) the following new sub22 section:

23 ‘‘(d) FREQUENCY AND PAYMENT LIMITS FOR

24 COLORECTAL CANCER SCREENING TESTS.—
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1 ‘‘(1) SCREENING FECAL-OCCULT BLOOD

2 TESTS.—

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

4 schedules under section 1833(h) with respect to

5 colorectal cancer screening tests consisting of

6 screening fecal-occult blood tests, except as pro7 vided by the Secretary under paragraph (4)(A),

8 the payment amount established for tests per9 formed—

10 ‘‘(i) in 1996 shall not exceed $5; and

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

12 exceed the limit on the payment amount

13 established under this subsection for such

14 tests for the preceding year, adjusted by

15 the applicable adjustment under section

16 1833(h) for tests performed in such year.

17 ‘‘(B) FREQUENCY LIMIT.—Subject to revi18 sion by the Secretary under paragraph (4)(B),

19 no payment may be made under this part for

20 colorectal cancer screening test consisting of a

21 screening fecal-occult blood test—

22 ‘‘(i) if the individual is under 50 years

23 of age; or
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1 ‘‘(ii) if the test is performed within

2 the 11 months after a previous screening

3 fecal-occult blood test.

4 ‘‘(2) SCREENING FLEXIBLE

5 SIGMOIDOSCOPIES.—

6 ‘‘(A) PAYMENT AMOUNT.—The Secretary

7 shall establish a payment amount under section

8 1848 with respect to colorectal cancer screening

9 tests consisting of screening flexible

10 sigmoidoscopies that is consistent with payment

11 amounts under such section for similar or relat12 ed services, except that such payment amount

13 shall be established without regard to sub14 section (a)(2)(A) of such section.

15 ‘‘(B) FREQUENCY LIMIT.—Subject to revi16 sion by the Secretary under paragraph (4)(B),

17 no payment may be made under this part for

18 a colorectal cancer screening test consisting of

19 a screening flexible sigmoidoscopy—

20 ‘‘(i) if the individual is under 50 years

21 of age; or

22 ‘‘(ii) if the procedure is performed

23 within the 47 months after a previous

24 screening flexible sigmoidoscopy.
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1 ‘‘(3) SCREENING COLONOSCOPY FOR INDIVID2 UALS AT HIGH RISK FOR COLORECTAL CANCER.—

3 ‘‘(A) PAYMENT AMOUNT.—The Secretary

4 shall establish a payment amount under section

5 1848 with respect to colorectal cancer screening

6 test consisting of a screening colonoscopy for

7 individuals at high risk for colorectal cancer (as

8 defined in section 1861(oo)(2)) that is consist9 ent with payment amounts under such section

10 for similar or related services, except that such

11 payment amount shall be established without

12 regard to subsection (a)(2)(A) of such section.

13 ‘‘(B) FREQUENCY LIMIT.—Subject to revi14 sion by the Secretary under paragraph (4)(B),

15 no payment may be made under this part for

16 a colorectal cancer screening test consisting of

17 a screening colonoscopy for individuals at high

18 risk for colorectal cancer if the procedure is

19 performed within the 23 months after a pre20 vious screening colonoscopy.

21 ‘‘(4) REDUCTIONS IN PAYMENT LIMIT AND RE22 VISION OF FREQUENCY.—

23 ‘‘(A) REDUCTIONS IN PAYMENT LIMIT FOR

24 SCREENING FECAL-OCCULT BLOOD TESTS.—

25 The Secretary shall review from time to time
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1 the appropriateness of the amount of the pay2 ment limit established for screening fecal-occult

3 blood tests under paragraph (1)(A). The Sec4 retary may, with respect to tests performed in

5 a year after 1998, reduce the amount of such

6 limit as it applies nationally or in any area to

7 the amount that the Secretary estimates is re8 quired to assure that such tests of an appro9 priate quality are readily and conveniently

10 available during the year.

11 ‘‘(B) REVISION OF FREQUENCY.—

12 ‘‘(i) REVIEW.—The Secretary shall re13 view periodically the appropriate frequency

14 for performing colorectal cancer screening

15 tests based on age and such other factors

16 as the Secretary believes to be pertinent.

17 ‘‘(ii) REVISION OF FREQUENCY.—The

18 Secretary, taking into consideration the re19 view made under clause (i), may revise

20 from time to time the frequency with

21 which such tests may be paid for under

22 this subsection, but no such revision shall

23 apply to tests performed before January 1,

24 1999.
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1 ‘‘(5) LIMITING CHARGES OF NONPARTICIPATING

2 PHYSICIANS.—

3 ‘‘(A) IN GENERAL.—In the case of a

4 colorectal cancer screening test consisting of a

5 screening flexible sigmoidoscopy or a screening

6 colonoscopy provided to an individual at high

7 risk for colorectal cancer for which payment

8 may be made under this part, if a

9 nonparticipating physician provides the proce10 dure to an individual enrolled under this part,

11 the physician may not charge the individual

12 more than the limiting charge (as defined in

13 section 1848(g)(2)).

14 ‘‘(B) ENFORCEMENT.—If a physician or

15 supplier knowing and willfully imposes a charge

16 in violation of subparagraph (A), the Secretary

17 may apply sanctions against such physician or

18 supplier in accordance with section

19 1842(j)(2).’’.

20 (2) SPECIAL RULE FOR SCREENING BARIUM

21 ENEMA.—If the Secretary of Health and Human

22 Services issues a determination under subsection

23 (a)(3) that screening barium enema should be cov24 ered as a colorectal cancer screening test under sec25 tion 1861(oo) of the Social Security Act (as added
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1 by subsection (a)(2)), the Secretary shall establish

2 frequency limits (including revisions of frequency

3 limits) for such procedure consistent with the fre4 quency limits for other colorectal cancer screening

5 tests under section 1834(d) of such Act (as added

6 by paragraph (1)), and shall establish payment lim7 its (including limits on charges of nonparticipating

8 physicians) for such procedure consistent with the

9 payment limits under part B of title XVIII of such

10 Act for diagnostic barium enema procedures.

11 (c) CONFORMING AMENDMENTS.—(1) Paragraphs

12 (1)(D) and (2)(D) of section 1833(a) of such Act (42

13 U.S.C. 1395l(a)) are each amended by striking ‘‘sub14 section (h)(1),’’ and inserting ‘‘subsection (h)(1) or section

15 1834(d)(1),’’.

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

17 1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’

18 and inserting ‘‘Subject to paragraphs (1) and (4)(A) of

19 section 1834(d), the Secretary’’.

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

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

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

23 than a colorectal cancer screening test consisting of a

24 screening colonoscopy provided to an individual at high
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1 risk for colorectal cancer or a screening flexible

2 sigmoidoscopy)’’.

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

4 is amended—

5 (A) in paragraph (1)—

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

7 at the end,

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

9 semicolon at the end and inserting ‘‘, and’’, and

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

11 subparagraph:

12 ‘‘(G) in the case of colorectal cancer screening

13 tests, which are performed more frequently than is

14 covered under section 1834(d);’’; and

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

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

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

18 SEC. 5. PROSTATE CANCER SCREENING TESTS.

19 (a) IN GENERAL.—Section 1861(s)(2) of the Social

20 Security Act (42 U.S.C. 1395x(s)(2)), as amended by sec21 tion 4(a)(1), is amended—

22 (1) by striking ‘‘and’’ at the end of subpara23 graph (P);

24 (2) by adding ‘‘and’’ at the end of subpara25 graph (Q); and
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1 (3) by adding at the end the following new sub2 paragraph:

3 ‘‘(R) prostate cancer screening tests (as defined

4 in subsection (pp)); and’’.

5 (b) TESTS DESCRIBED.—Section 1861 of such Act

6 (42 U.S.C. 1395x), as amended by section 4(a)(2), is

7 amended by adding at the end the following new sub8 section:

9 ‘‘Prostate Cancer Screening Tests

10 ‘‘(pp)(1) The term ‘prostate cancer screening test’

11 means a test that consists of any (or all) of the procedures

12 described in paragraph (2) provided for the purpose of

13 early detection of prostate cancer to a man over 50 years

14 of age who has not had such a test during the preceding

15 year.

16 ‘‘(2) The procedures described in this paragraph are

17 as follows:

18 ‘‘(A) A digital rectal examination.

19 ‘‘(B) A prostate-specific antigen blood test.

20 ‘‘(C) For years beginning after 1998, such

21 other procedures as the Secretary finds appropriate

22 for the purpose of early detection of prostate cancer,

23 taking into account changes in technology and

24 standards of medical practice, availability, effective-
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1 ness, costs, and such other factors as the Secretary

2 considers appropriate.’’.

3 (c) PAYMENT FOR PROSTATE-SPECIFIC ANTIGEN

4 BLOOD TEST UNDER CLINICAL DIAGNOSTIC LABORA5 TORY TEST FEE SCHEDULES.—Section 1833(h)(1)(A) of

6 such Act (42 U.S.C. 1395l(h)(1)(A)) is amended by in7 serting after ‘‘laboratory tests’’ the following: ‘‘(including

8 prostate cancer screening tests under section 1861(pp)

9 consisting of prostate-specific antigen blood tests)’’.

10 (d) CONFORMING AMENDMENT.—Section 1862(a) of

11 such Act (42 U.S.C. 1395y(a)), as amended by section

12 4(c)(4), is amended—

13 (1) in paragraph (1)—

14 (A) in subparagraph (F), by striking

15 ‘‘and’’ at the end,

16 (B) in subparagraph (G), by striking the

17 semicolon at the end and inserting ‘‘, and’’, and

18 (C) by adding at the end the following new

19 subparagraph:

20 ‘‘(H) in the case of prostate cancer screening

21 tests (as defined in section 1861(oo)), which are per22 formed more frequently than is covered under such

23 section;’’; and

24 (2) in paragraph (7), by striking ‘‘or (G)’’ and

25 inserting ‘‘(G), or (H)’’.
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1 SEC. 6. DIABETES SCREENING BENEFITS.

2 (a) DIABETES OUTPATIENT SELF-MANAGEMENT

3 TRAINING SERVICES.—

4 (1) IN GENERAL.—Section 1861(s)(2) of the

5 Social Security Act (42 U.S.C. 1395x(s)(2)), as

6 amended by sections 4(a)(1) and 5(a), is amended—

7 (A) by striking ‘‘and’’ at the end of sub8 paragraph (Q);

9 (B) by adding ‘‘and’’ at the end of sub10 paragraph (R); and

11 (C) by adding at the end the following new

12 subparagraph:

13 ‘‘(S) diabetes outpatient self-management train14 ing services (as defined in subsection (qq)); and’’.

15 (2) DEFINITION.—Section 1861 of such Act

16 (42 U.S.C. 1395x), as amended by sections 4(a)(2)

17 and 5(b), is amended by adding at the end the fol18 lowing new subsection:

19 ‘‘DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING

20 SERVICES

21 ‘‘(qq)(1) The term ‘diabetes outpatient self-manage22 ment training services’ means educational and training

23 services furnished to an individual with diabetes by or

24 under arrangements with a certified provider (as described

25 in paragraph (2)(A)) in an outpatient setting by an indi26 vidual or entity who meets the quality standards described
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1 in paragraph (2)(B), but only if the physician who is man2 aging the individual’s diabetic condition certifies that such

3 services are needed under a comprehensive plan of care

4 related to the individual’s diabetic condition to provide the

5 individual with necessary skills and knowledge (including

6 skills related to the self-administration of injectable drugs)

7 to participate in the management of the individual’s condi8 tion.

9 ‘‘(2) In paragraph (1)—

10 ‘‘(A) a ‘certified provider’ is an individual or

11 entity that, in addition to providing diabetes out12 patient self-management training services, provides

13 other items or services for which payment may be

14 made under this title; and

15 ‘‘(B) an individual or entity meets the quality

16 standards described in this paragraph if the individ17 ual or entity meets quality standards established by

18 the Secretary, except that the individual or entity

19 shall be deemed to have met such standards if the

20 individual or entity meets applicable standards origi21 nally established by the National Diabetes Advisory

22 Board and subsequently revised by organizations

23 who participated in the establishment of standards

24 by such Board, or is recognized by the American Di-
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1 abetes Association as meeting standards for furnish2 ing the services.’’.

3 (3) CONSULTATION WITH ORGANIZATIONS IN

4 ESTABLISHING PAYMENT AMOUNTS FOR SERVICES

5 PROVIDED BY PHYSICIANS.—In establishing payment

6 amounts under section 1848(a) of the Social Secu7 rity Act for physicians’ services consisting of diabe8 tes outpatient self-management training services, the

9 Secretary of Health and Human Services shall con10 sult with appropriate organizations, including the

11 American Diabetes Association, in determining the

12 relative value for such services under section

13 1848(c)(2) of such Act.

14 (b) BLOOD-TESTING STRIPS FOR INDIVIDUALS WITH

15 DIABETES.—

16 (1) INCLUDING STRIPS AS DURABLE MEDICAL

17 EQUIPMENT.—Section 1861(n) of such Act (42

18 U.S.C. 1395x(n)) is amended by striking the semi19 colon in the first sentence and inserting the follow20 ing: ‘‘, and includes blood-testing strips for individ21 uals with diabetes without regard to whether the in22 dividual has Type I or Type II diabetes or to the in23 dividual’s use of insulin (as determined under stand24 ards established by the Secretary in consultation

25 with the American Diabetes Association);’’.
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1 (2) PAYMENT FOR STRIPS BASED ON METH2 ODOLOGY FOR INEXPENSIVE AND ROUTINELY PUR3 CHASED EQUIPMENT.—Section 1834(a)(2)(A) of

4 such Act (42 U.S.C. 1395m(a)(2)(A)) is amended—

5 (A) by striking ‘‘or’’ at the end of clause

6 (ii);

7 (B) by adding ‘‘or’’ at the end of clause

8 (iii); and

9 (C) by inserting after clause (iii) the fol10 lowing new clause:

11 ‘‘(iv) which is a blood-testing strip for

12 an individual with diabetes,’’.

13 (c) ESTABLISHMENT OF OUTCOME MEASURES FOR

14 BENEFICIARIES WITH DIABETES.—

15 (1) IN GENERAL.—The Secretary of Health and

16 Human Services, in consultation with appropriate

17 organizations (including the American Diabetes As18 sociation), shall establish outcome measures, includ19 ing glysolated hemoglobin (past 90-day average

20 blood sugar levels), for purposes of evaluating the

21 improvement of the health status of medicare bene22 ficiaries with diabetes mellitus.

23 (2) RECOMMENDATIONS FOR MODIFICATIONS

24 TO SCREENING BENEFITS.—Taking into account in25 formation on the health status of medicare bene-
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1 ficiaries with diabetes mellitus as measured under

2 the outcome measures established under paragraph

3 (1), the Secretary shall from time to time submit

4 recommendations to Congress regarding modifica5 tions to the coverage of services for such bene6 ficiaries under the medicare program.

7 SEC. 7. EFFECTIVE DATE.

8 The amendments made by this Act shall apply to

9 items and services furnished on or after January 1, 1996.

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