I

106TH CONGRESS

1ST SESSION H. R. 1968

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

benefits under the Medicare Program to prevent or delay the onset

of illnesses, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

MAY 26, 1999

Mr. STARK 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 additional benefits under the Medicare Program to

prevent or delay the onset of illnesses, and for other

purposes.

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 Care Improvement Act of 1999’’.
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1 SEC. 2. AUTHORITY TO PROVIDE PREVENTIVE SERVICES

2 UNDER PART B OF THE MEDICARE PROGRAM.

3 (a) PREVENTIVE SERVICES BENEFIT.—

4 (1) IN GENERAL.—Section 1861(s) of the So5 cial Security Act (42 U.S.C. 1395x(s)) is amended—

6 (A) by redesignating paragraphs (16) and

7 (17) as paragraphs (17) and (18), respectively;

8 and

9 (B) by inserting after paragraph (15) the

10 following new paragraph:

11 ‘‘(16) qualified preventive services, as defined in

12 subsection (uu);’’.

13 (2) CONFORMING AMENDMENTS.—Sections

14 1864(a) 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of

15 such Act (42 U.S.C. 1395aa(a), 1396a(a)(9)(C), and

16 1396n(a)(1)(B)(ii)(I)) are each amended by striking

17 ‘‘paragraphs (16) and (17)’’ each place it appears

18 and inserting ‘‘paragraphs (17) and (18)’’.

19 (b) DEFINITION OF PREVENTIVE SERVICES.—Sec20 tion 1861 of such Act (42 U.S.C. 1395x) is amended by

21 adding at the end the following new subsection:

22 ‘‘Qualified Preventive Services

23 ‘‘(uu)(1) Subject to paragraph (2), the term ‘quali24 fied preventive services’ means items and services deter25 mined by the Secretary to be reasonable and necessary for

26 the prevention or early detection of an illness or disability.
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1 ‘‘(2) An item or service described in paragraph (1)

2 shall be qualified as a preventive service if the Secretary

3 determines by authoritative evidence that the provision of

4 such item or service is cost effective. In determining if

5 such an item or service is cost effective, the Secretary shall

6 consider the following:

7 ‘‘(A) Whether furnishing such an item or serv8 ice for an illness or disability results in reductions

9 in estimated expenditures under the Social Security

10 Act for the illness or disability, or avoids treatment

11 in a more expensive setting.

12 ‘‘(B) Whether the item or service improves the

13 health of the individual for whom the item or service

14 is furnished.

15 ‘‘(C) In the case of an individual entitled to

16 benefits under this title by reason of section 226(b),

17 whether the item or service facilitates the return to

18 work of the individual.’’.

19 (c) EXCLUSION FROM COVERAGE CONFORMING

20 AMENDMENT.—Section 1862(a)(1)(B) of such Act (42

21 U.S.C. 1395y(a)(1)(B)) is amended by striking ‘‘section

22 1861(s)(10)’’ and inserting ‘‘section 1834(e)(6)’’.
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1 SEC. 3. PAYMENT FOR PREVENTIVE SERVICES.

2 (a) IN GENERAL.—Section 1834 of the Social Secu3 rity Act (42 U.S.C. 1395m) is amended by inserting after

4 subsection (d) the following new subsection:

5 ‘‘(e) ALTERNATIVE PAYMENT FOR PREVENTIVE

6 SERVICES.—

7 ‘‘(1) GENERAL PAYMENT RULE.—

8 ‘‘(A) QUALIFIED PREVENTIVE SERVICES.—

9 The Secretary shall establish by regulation a

10 payment amount for qualified preventive serv11 ices, as defined in section 1861(uu).

12 ‘‘(B) OTHER PREVENTIVE SERVICES.—The

13 Secretary may establish by regulation a pay14 ment amount for each type of preventive service

15 described in subparagraphs (A) through (H) of

16 paragraph (6).

17 ‘‘(2) MINIMUM PAYMENT AMOUNT.—In the case

18 of a preventive service described in paragraph (6)

19 that may be performed as a diagnostic or thera20 peutic service under this title, the payment amount

21 under this subsection for a service performed as a

22 preventive service may not be less than the payment

23 amount established under this title for such service

24 performed as a diagnostic or therapeutic service.

25 ‘‘(3) MANNER OF PAYMENT.—In the case of a

26 preventive service described in paragraph (6) that
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1 may be performed as a diagnostic or therapeutic

2 service under this title, the Secretary shall apply the

3 same method of payment under this subsection for

4 a service performed as a preventive service as the

5 Secretary applies under this title for such service

6 performed as a diagnostic or therapeutic service.

7 ‘‘(4) AUTHORITY TO WAIVE COINSURANCE.—

8 Notwithstanding any other provision of this title, in

9 the case of a preventive service described in para10 graph (6), the Secretary may waive the imposition of

11 any applicable coinsurance amount with respect to

12 such service.

13 ‘‘(5) PROHIBITION ON BALANCE BILLING.—The

14 provisions of subparagraphs (A) and (B) of section

15 1842(b)(18) shall apply to the furnishing of preven16 tive services described in paragraph (6) for which

17 payment is made under this subsection in the same

18 manner as such subparagraphs apply to services fur19 nished by a practitioner described in subparagraph

20 (C) of such section.

21 ‘‘(6) PREVENTIVE SERVICES DESCRIBED.—For

22 purposes of this subsection, the preventive services

23 described in this paragraph are any of the following

24 services:
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1 ‘‘(A) Antigens (under section

2 1861(s)(2)(G)).

3 ‘‘(B) Prostate cancer screening tests (as

4 defined in section 1861(oo)).

5 ‘‘(C) Colorectal cancer screening tests (as

6 defined in section 1861(pp)).

7 ‘‘(D) Diabetes outpatient self-management

8 training services (as defined in section

9 1861(qq)).

10 ‘‘(E)(i) Pneumococcal vaccine and its ad11 ministration and influenza vaccine and its ad12 ministration (under section 1861(s)(10)(A)).

13 ‘‘(ii) Hepatitis B vaccine and its adminis14 tration (under section 1861(s)(10)(B)).

15 ‘‘(F) Screening mammography (as defined

16 in section 1861(jj)).

17 ‘‘(G) Screening pap smear and screening

18 pelvic exam (as defined in paragraphs (1) and

19 (2), respectively, of section 1861(nn)).

20 ‘‘(H) Bone mass measurement (as defined

21 in section 1861(rr)).

22 ‘‘(I) Qualified preventive services (as de23 fined in section 1861(uu)).’’.

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

25 section 1833(b) of such Act (42 U.S.C. 1395l(b)) is
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1 amended by striking ‘‘, (5) such deductible’’ and all that

2 follows through the period and inserting: ‘‘, and (5) such

3 deductible shall not apply with respect to preventive serv4 ices (as described in section 1834(e)(6)).’’.

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

6 1833(a)(1)(B) of such Act (42 U.S.C. 1395l(a)(1)(B)) is

7 amended by inserting ‘‘subject to section 1834(e),’’ before

8 ‘‘the amounts paid shall be 100 percent of the reasonable

9 charges for such items and services,’’.

10 (2) Section 1833(a)(2)(G) of such Act (42 U.S.C.

11 1395l(a)(2)(G)) is amended by inserting ‘‘subject to sec12 tion 1834(e),’’ before ‘‘with respect to items and services’’.

13 (3) Section 1834(c)(1)(C) of such Act (42 U.S.C.

14 1395m(c)) is amended by striking ‘‘the amount of the pay15 ment’’ and inserting ‘‘except as provided by the Secretary

16 under subsection (e), the amount of the payment’’.

17 (4) Section 1834(d) of such Act (42 U.S.C.

18 1395m(d)) is amended—

19 (A) in paragraph (1)(A), by striking ‘‘The pay20 ment amount’’ and inserting ‘‘Except as provided by

21 the Secretary under subsection (e), the payment

22 amount’’; and

23 (B) in paragraphs (2)(A) and (3)(A), by strik24 ing ‘‘payment under section 1848’’ each place it ap25 pears and inserting ‘‘except as provided by the Sec-
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1 retary under subsection (e), payment under section

2 1848’’.

3 (5) Section 1848(g)(2)(C) of such Act (42 U.S.C.

4 1395w–4(g)(2)(C)) is amended—

5 (A) by striking ‘‘For’’ and inserting ‘‘(i) Sub6 ject to clause (ii), for’’; and

7 (B) by adding at the end the following new

8 clause:

9 ‘‘(ii) For physicians’ services consisting of

10 preventive services (as described in section

11 1834(e)(6)) furnished on or after February 1,

12 2000, the ‘limiting charge’ shall be 100 percent

13 of the recognized payment amount under this

14 part for nonparticipating physicians or for non15 participating suppliers or other persons.’’.

16 (6) Section 1848(g)(2)(D) of such Act (42 U.S.C.

17 1395w–4(g)(2)(D)) is amended by striking ‘‘the fee sched18 ule amount determined under subsection (a)’’ and all that

19 follows and inserting ‘‘the fee schedule amount determined

20 under subsection (a), in the case of preventive services (as

21 described in section 1834(e)(6)) the amount determined

22 by the Secretary under section 1834(e), or, if payment

23 under this part is made on a basis other than the fee

24 schedule under this section or other than the amount es-
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1 tablished under section 1834(e) with respect to such pre2 ventive services, 95 percent of the other payment basis.’’.

3 SEC. 4. EFFECTIVE DATE.

4 The amendments made by this Act apply to items and

5 services furnished on or after February 1, 2000.

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