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103D CONGRESS

1ST SESSION H. R. 19

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

of certain preventive services under part B of the medicare program.

IN THE HOUSE OF REPRESENTATIVES

JANUARY 5, 1993

Mr. ROSTENKOWSKI (for himself and Mr. STARK) introduced the following

bill; which was referred to the Committee on Ways and Means, Energy

and Commerce

A BILL

To amend title XVIII of the Social Security Act to provide

for coverage of certain preventive 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 ‘‘Medicare Prevention

5 Benefit Act of 1993’’.

6 SEC. 2. ANNUAL SCREENING MAMMOGRAPHY.

7 (a) ANNUAL SCREENING MAMMOGRAPHY FOR

8 WOMEN OVER AGE 64.—Section 1834(c)(2)(A) of the So-
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1 cial Security Act (42 U.S.C. 1395m(b)(2)(A)) is amend2 ed—

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

4 years of age,’’; and

5 (2) by striking clause (v).

6 (b) EFFECTIVE DATE.—The amendments made by

7 subsection (a) shall apply to screening mammography per8 formed on or after January 1, 1994.

9 SEC. 3. COVERAGE OF COLORECTAL SCREENING.

10 (a) IN GENERAL.—Section 1834 of the Social Secu11 rity Act (42 U.S.C. 1395m) is amended by inserting after

12 subsection (c) the following new subsection:

13 ‘‘(d) FREQUENCY AND PAYMENT LIMITS FOR

14 SCREENING FECAL-OCCULT BLOOD TESTS AND SCREEN15 ING FLEXIBLE SIGMOIDOSCOPIES.—

16 ‘‘(1) SCREENING FECAL-OCCULT BLOOD

17 TESTS.—

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

19 schedules under section 1833(h) with respect to

20 screening fecal-occult blood tests provided for

21 the purpose of early detection of colon cancer,

22 except as provided by the Secretary under para23 graph (3)(A), the payment amount established

24 for tests performed—

25 ‘‘(i) in 1994 shall not exceed $5; and
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1 ‘‘(ii) in a subsequent year, shall not

2 exceed the limit on the payment amount

3 established under this subsection for such

4 tests for the preceding year, adjusted by

5 the applicable adjustment under section

6 1833(h) for tests performed in such year.

7 ‘‘(B) FREQUENCY LIMIT.—Subject to revi8 sion 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—

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

14 of age; or

15 ‘‘(ii) if the test is performed within 11

16 months after a previous screening fecal-oc17 cult blood test.

18 ‘‘(2) SCREENING FLEXIBLE SIGMOIDOS19 COPIES.—

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

21 shall establish a payment amount under section

22 1848 with respect to screening flexible

23 sigmoidoscopies provided for the purpose of

24 early detection of colon cancer that is consistent

25 with payment amounts under such section for
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1 similar or related services, except that such

2 payment amount shall be established without

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

4 ‘‘(B) FREQUENCY LIMIT.—Subject to revi5 sion by the Secretary under paragraph (3)(B),

6 no payment may be made under this part for

7 a screening flexible sigmoidoscopy provided to

8 an individual for the purpose of early detection

9 of colon cancer—

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

11 of age; or

12 ‘‘(ii) if the procedure is performed

13 within 59 months after a previous screen14 ing flexible sigmoidoscopy.

15 ‘‘(3) REDUCTIONS IN PAYMENT LIMIT AND RE16 VISION OF FREQUENCY.—

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

18 The Secretary shall review from time to time

19 the appropriateness of the amount of the pay20 ment limit established for screening fecal-occult

21 blood tests under paragraph (1)(A). The Sec22 retary may, with respect to tests performed in

23 a year after 1996, reduce the amount of such

24 limit as it applies nationally or in any area to

25 the amount that the Secretary estimates is re-
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1 quired to assure that such tests of an appro2 priate quality are readily and conveniently

3 available during the year.

4 ‘‘(B) REVISION OF FREQUENCY.—

5 ‘‘(i) REVIEW.—The Secretary, in con6 sultation with the Director of the National

7 Cancer Institute, shall review periodically

8 the appropriate frequency for performing

9 screening fecal-occult blood tests and

10 screening flexible sigmoidoscopies based on

11 age and such other factors as the Sec12 retary believes to be pertinent.

13 ‘‘(ii) REVISION OF FREQUENCY.—The

14 Secretary, taking into consideration the re15 view made under clause (i), may revise

16 from time to time the frequency with

17 which such tests and procedures may be

18 paid for under this subsection, but no such

19 revision shall apply to tests or procedures

20 performed before January 1, 1997.’’.

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

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

23 U.S.C. 1395l(a)) are each amended by striking ‘‘sub24 section (h)(1),’’ and inserting ‘‘subsection (h)(1) or section

25 1834(d)(1),’’.
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1 (2) Section 1833(h)(1)(A) of such Act (42 U.S.C.

2 1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’

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

4 section 1834(d), the Secretary’’.

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

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

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

8 than a screening flexible sigmoidoscopy provided to an in9 dividual for the purpose of early detection of colon can10 cer)’’.

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

12 is amended—

13 (A) in paragraph (1)—

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

15 at the end,

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

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

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

19 subparagraph:

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

21 blood tests and screening flexible

22 sigmoidoscopies provided for the purpose of

23 early detection of colon cancer, which are per24 formed more frequently than is covered under

25 section 1834(d);’’; 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 (c) EFFECTIVE DATE.—The amendments made by

5 this section shall apply to screening fecal-occult blood tests

6 and screening flexible sigmoidoscopies performed on or

7 after January 1, 1994.

8 SEC. 4. COVERAGE OF CERTAIN IMMUNIZATIONS.

9 (a) IN GENERAL.—Section 1861(s)(10) of the Social

10 Security Act (42 U.S.C. 1395x(s)(10)) is amended—

11 (1) in subparagraph (A)—

12 (A) by striking ‘‘, subject to section

13 4071(b) of the Omnibus Budget Reconciliation

14 Act of 1987,’’, and

15 (B) by striking ‘‘; and’’ and inserting a

16 comma;

17 (2) in subparagraph (B), by striking the semi18 colon at the end and inserting ‘‘, and’’; and

19 (3) by adding at the end the following new sub20 paragraph:

21 ‘‘(C) tetanus-diphtheria booster and its ad22 ministration;’’.

23 (b) LIMITATION ON FREQUENCY.—Section

24 1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as

25 amended by section 3(b)(4)(A), is amended—
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1 (1) in subparagraph (F), by striking ‘‘and’’ at

2 the end;

3 (2) in subparagraph (G), by striking the semi4 colon at the end and inserting ‘‘, and’’; and

5 (3) by adding at the end the following new sub6 paragraph:

7 ‘‘(H) in the case of an influenza vaccine,

8 which is administered within the 11 months

9 after a previous influenza vaccine, and, in the

10 case of a tetanus-diphtheria booster, which is

11 administered within the 119 months after a

12 previous tetanus-diphtheria booster;’’.

13 (c) CONFORMING AMENDMENT.—Section 1862(a)(7)

14 of such Act (42 U.S.C. 1395y(a)(7)), as amended by sec15 tion 3(b)(4)(B), is amended by striking ‘‘or (G)’’ and in16 serting ‘‘(G), or (H)’’.

17 (d) EFFECTIVE DATE.—The amendments made by

18 this section shall apply to influenza vaccines and tetanus19 diphtheria boosters administered on or after January 1,

20 1994.

21 SEC. 5. COVERAGE OF WELL-CHILD CARE.

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

23 Security Act (42 U.S.C. 1395x(s)(2)) is amended—

24 (1) by striking ‘‘and’’ at the end of subpara25 graph (O);
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1 (2) by striking the semicolon at the end of sub2 paragraph (P) and inserting ‘‘; and’’; and

3 (3) by adding at the end the following new sub4 paragraph:

5 ‘‘(Q) well-child services (as defined in sub6 section (ll)(1)) provided to an individual entitled to

7 benefits under this title who is under 7 years of

8 age;’’.

9 (b) SERVICES DEFINED.—Section 1861 of such Act

10 (42 U.S.C. 1395x) is amended—

11 (1) by redesignating the subsection (jj) as sub12 section (kk); and

13 (2) by inserting after subsection (kk) (as so re14 designated) the following new subsection:

15 ‘‘Well-Child Services

16 ‘‘(ll)(1) The term ‘well-child services’ means well17 child care, including routine office visits, routine immuni18 zations (including the vaccine itself), routine laboratory

19 tests, and preventive dental care, provided in accordance

20 with the periodicity schedule established with respect to

21 the services under paragraph (2).

22 ‘‘(2) The Secretary, in consultation with the Amer23 ican Academy of Pediatrics, the Advisory Committee on

24 Immunization Practices, and other entities considered ap25 propriate by the Secretary, shall establish a schedule of
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1 periodicity which reflects the appropriate frequency with

2 which the services referred to in paragraph (1) should be

3 provided to healthy children.’’.

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

5 1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as

6 amended by sections 3(b)(4)(A) and 4(b), is amended—

7 (A) in subparagraph (G), by striking ‘‘and’’ at

8 the end;

9 (B) in subparagraph (H), by striking the semi10 colon at the end and inserting ‘‘, and’’; and

11 (C) by adding at the end the following new sub12 paragraph:

13 ‘‘(I) in the case of well-child services, which are

14 provided more frequently than is provided under the

15 schedule of periodicity established by the Secretary

16 under section 1861(ll)(2) for such services;’’.

17 (2) Section 1862(a)(7) of such Act (42 U.S.C.

18 1395y(a)(7)), as amended by sections 3(b)(4)(B) and 4(c),

19 is amended by striking ‘‘or (H)’’ and inserting ‘‘(H), or

20 (I)’’.

21 (d) EFFECTIVE DATE.—The amendments made by

22 this section shall apply to well-child services provided on

23 or after January 1, 1994.
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1 SEC. 6. DEMONSTRATION PROJECTS FOR COVERAGE OF

2 OTHER PREVENTIVE SERVICES.

3 (a) ESTABLISHMENT.—The Secretary of Health and

4 Human Services shall establish and provide for a series

5 of ongoing demonstration projects under which the Sec6 retary shall provide for coverage of the preventive services

7 described in subsection (c) under the medicare program

8 in order to determine—

9 (1) the feasibility and desirability of expanding

10 coverage of medical and other health services under

11 the medicare program to include coverage of such

12 services for all individuals enrolled under part B of

13 title XVIII of the Social Security Act; and

14 (2) appropriate methods for the delivery of

15 those services to medicare beneficiaries.

16 (b) SITES FOR PROJECT.—The Secretary shall pro17 vide for the conduct of the demonstration projects estab18 lished under subsection (a) at the sites at which the Sec19 retary conducts the demonstration program established

20 under section 9314 of the Consolidated Omnibus Budget

21 Reconciliation Act of 1985 and at such other sites as the

22 Secretary considers appropriate.

23 (c) SERVICES COVERED UNDER PROJECTS.—The

24 Secretary shall cover the following services under the se25 ries of demonstration projects established under sub26 section (a):
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1 (1) Glaucoma screening.

2 (2) Cholesterol screening and cholesterol-reduc3 ing drug therapies.

4 (3) Screening and treatment for osteoporosis,

5 including tests for bone-marrow density and hor6 mone replacement therapy.

7 (4) Screening services for pregnant women, in8 cluding ultra-sound and clamydial testing and ma9 ternal serum alfa-protein.

10 (5) One-time comprehensive assessment for in11 dividuals beginning at age 65 or 75.

12 (6) Prostate-specific antigen (PSA) testing.

13 (7) Other services considered appropriate by the

14 Secretary.

15 (d) REPORTS TO CONGRESS.—Not later than October

16 1, 1995, and every 2 years thereafter, the Secretary shall

17 submit a report to the Committee on Finance of the Sen18 ate and the Committee on Ways and Means and the Com19 mittee on Energy and Commerce of the House of Rep20 resentatives describing findings made under the dem21 onstration projects conducted pursuant to subsection (a)

22 during the preceding 2-year period and the Secretary’s

23 plans for the demonstration projects during the succeeding

24 2-year period.
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1 (e) AUTHORIZATION OF APPROPRIATIONS.—There

2 are authorized to be appropriated from the Federal Sup3 plementary Medical Insurance Trust Fund for expenses

4 incurred in carrying out the series of demonstration

5 projects established under subsection (a) the following

6 amounts:

7 (1) $4,000,000 for fiscal year 1994.

8 (2) $4,000,000 for fiscal year 1995.

9 (3) $5,000,000 for fiscal year 1996.

10 (4) $5,000,000 for fiscal year 1997.

11 (5) $6,000,000 for fiscal year 1998.

12 SEC. 7. OTA STUDY OF PROCESS FOR REVIEW OF MEDI13 CARE COVERAGE OF PREVENTIVE SERVICES.

14 (a) STUDY.—The Director of the Office of Tech15 nology Assessment (hereafter referred to as the ‘‘Direc16 tor’’) shall, subject to the approval of the Technology As17 sessment Board, conduct a study to develop a process for

18 the regular review for the consideration of coverage of pre19 ventive services under the medicare program, and shall in20 clude in such study a consideration of different types of

21 evaluations, the use of demonstration projects to obtain

22 data and experience, and the types of measures, outcomes,

23 and criteria that should be used in making coverage deci24 sions.
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1 (b) REPORT.—Not later than 2 years after the date

2 of the enactment of this Act, the Director shall submit

3 a report to the Committee on Finance of the Senate and

4 the Committee on Ways and Means and the Committee

5 on Energy and Commerce of the House of Representatives

6 on the study conducted under subsection (a).

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