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103D CONGRESS

2D SESSION H. R. 4167

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

of colorectal screening under part B of the medicare program.

IN THE HOUSE OF REPRESENTATIVES

APRIL 12, 1994

Mr. CARDIN introduced the following bill; which was referred jointly to the

Committees on Ways and Means and Energy and Commerce

A BILL

To amend title XVIII of the Social Security Act to provide

for coverage of colorectal screening 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 ‘‘Colon Cancer Screen5 ing and Prevention Act’’.

6 SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREEN7 ING.

8 (a) IN GENERAL.—Section 1834 of the Social Secu9 rity Act (42 U.S.C. 1395m) is amended by inserting after

10 subsection (c) the following new subsection:
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1 ‘‘(d) FREQUENCY AND PAYMENT LIMITS FOR

2 SCREENING FECAL-OCCULT BLOOD TESTS, SCREENING

3 FLEXIBLE SIGMOIDOSCOPIES, AND SCREENING

4 COLONOSCOPY.—

5 ‘‘(1) SCREENING FECAL-OCCULT BLOOD

6 TESTS.—

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

8 schedules under section 1833(h) with respect to

9 screening fecal-occult blood tests provided for

10 the purpose of early detection of colon cancer,

11 except as provided by the Secretary under para12 graph (3)(A), the payment amount established

13 for tests performed—

14 ‘‘(i) in 1995 shall not exceed $5; and

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

16 exceed the limit on the payment amount

17 established under this subsection for such

18 tests for the preceding year, adjusted by

19 the applicable adjustment under section

20 1833(h) for tests performed in such year.

21 ‘‘(B) FREQUENCY LIMIT.—Subject to revi22 sion by the Secretary under paragraph (3)(B),

23 no payment may be made under this part for

24 a screening fecal-occult blood test provided to
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1 an individual for the purpose of early detection

2 of colon cancer—

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

4 of age; or

5 ‘‘(ii) if the test is performed within

6 the 11 months after a previous screening

7 fecal-occult blood test.

8 ‘‘(2) SCREENING FLEXIBLE SIGMOID9 OSCOPIES.—

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

11 shall establish a payment amount under section

12 1848 with respect to screening flexible

13 sigmoidoscopies provided for the purpose of

14 early detection of colon cancer that is consistent

15 with payment amounts under such section for

16 similar or related services, except that such

17 payment amount shall be established without

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

19 ‘‘(B) FREQUENCY LIMIT.—Subject to revi20 sion by the Secretary under paragraph (4)(B),

21 no payment may be made under this part for

22 a screening flexible sigmoidoscopy provided to

23 an individual for the purpose of early detection

24 of colon cancer—
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1 ‘‘(i) if the individual is under 50 years

2 of age; or

3 ‘‘(ii) if the procedure is performed

4 within the 47 months after a previous

5 screening flexible sigmoidoscopy.

6 ‘‘(3) SCREENING COLONOSCOPY FOR INDIVID7 UALS AT HIGH RISK FOR COLORECTAL CANCER.—

8 ‘‘(A) PAYMENT AMOUNT.—The Secretary

9 shall establish a payment amount under section

10 1848 with respect to screening colonoscopy for

11 individuals at high risk for colorectal cancer (as

12 determined in accordance with criteria estab13 lished by the Secretary) provided for the pur14 pose of early detection of colon cancer that is

15 consistent with payment amounts under such

16 section for similar or related services, except

17 that such payment amount shall be established

18 without regard to subsection (a)(2)(A) of such

19 section.

20 ‘‘(B) FREQUENCY LIMIT.—Subject to revi21 sion by the Secretary under paragraph (4)(B),

22 no payment may be made under this part for

23 a screening colonoscopy for individuals at high

24 risk for colorectal cancer provided to an individ25 ual for the purpose of early detection of colon
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1 cancer if the procedure is performed within the

2 23 months after a previous screening

3 colonoscopy.

4 ‘‘(C) FACTORS CONSIDERED IN ESTAB5 LISHING CRITERIA FOR DETERMINING INDIVID6 UALS AT HIGH RISK.—In establishing criteria

7 for determining whether an individual is at high

8 risk for colorectal cancer for purposes of this

9 paragraph, the Secretary shall take into consid10 eration family history, prior experience of can11 cer or precursor neoplastic polyps, a history of

12 chronic digestive disease condition (including in13 flammatory bowel disease, Crohn’s Disease, or

14 ulcerative colitis), the presence of any appro15 priate recognized gene markers for colorectal

16 cancer, and other appropriate factors.

17 ‘‘(4) REDUCTIONS IN PAYMENT LIMIT AND RE18 VISION OF FREQUENCY.—

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

20 The Secretary shall review from time to time

21 the appropriateness of the amount of the pay22 ment limit established for screening fecal-occult

23 blood tests under paragraph (1)(A). The Sec24 retary may, with respect to tests performed in

25 a year after 1997, reduce the amount of such
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1 limit as it applies nationally or in any area to

2 the amount that the Secretary estimates is re3 quired to assure that such tests of an appro4 priate quality are readily and conveniently

5 available during the year.

6 ‘‘(B) REVISION OF FREQUENCY.—

7 ‘‘(i) REVIEW.—The Secretary shall re8 view periodically the appropriate frequency

9 for performing screening fecal-occult blood

10 tests, screening flexible sigmoidoscopies,

11 and screening colonoscopy based on age

12 and such other factors as the Secretary be13 lieves to be pertinent.

14 ‘‘(ii) REVISION OF FREQUENCY.—The

15 Secretary, taking into consideration the re16 view made under clause (i), may revise

17 from time to time the frequency with

18 which such tests and procedures may be

19 paid for under this subsection, but no such

20 revision shall apply to tests or procedures

21 performed before January 1, 1998.

22 ‘‘(5) LIMITING CHARGES OF NONPARTICIPATING

23 PHYSICIANS.—

24 ‘‘(A) IN GENERAL.—In the case of a

25 screening flexible sigmoidoscopy provided to an
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1 individual for the purpose of early detection of

2 colon cancer or a screening colonoscopy pro3 vided to an individual at high risk for colorectal

4 cancer for the purpose of early detection of

5 colon cancer for which payment may be made

6 under this part, if a nonparticipating physician

7 provides the procedure to an individual enrolled

8 under this part, the physician may not charge

9 the individual more than the limiting charge (as

10 defined in section 1848(g)(2)).

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

12 supplier knowing and willfully imposes a charge

13 in violation of subparagraph (A), the Secretary

14 may apply sanctions against such physician or

15 supplier in accordance with section

16 1842(j)(2).’’.

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

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

19 U.S.C. 1395l(a)) are each amended by striking ‘‘sub20 section (h)(1),’’ and inserting ‘‘subsection (h)(1) or section

21 1834(d)(1),’’.

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

23 1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’

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

25 section 1834(d), the Secretary’’.
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1 (3) Clauses (i) and (ii) of section 1848(a)(2)(A) of

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

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

4 than a screening flexible sigmoidoscopy provided to an in5 dividual for the purpose of early detection of colon cancer

6 or a screening colonoscopy provided to an individual at

7 high risk for colorectal cancer for the purpose of early de8 tection of colon cancer)’’.

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

10 is amended—

11 (A) in paragraph (1)—

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

13 at the end,

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

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

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

17 subparagraph:

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

19 tests, screening flexible sigmoidoscopies, and screen20 ing colonoscopy provided for the purpose of early de21 tection of colon cancer, which are performed more

22 frequently than is covered under section 1834(d);’’;

23 and
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1 (B) in paragraph (7), by striking ‘‘paragraph

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

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

4 SEC. 3. EFFECTIVE DATE.

5 The amendments made by section 2 shall apply to

6 screening fecal-occult blood tests, screening flexible

7 sigmoidoscopies, and screening colonoscopy performed on

8 or after January 1, 1995.

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