I
105TH CONGRESS
1ST SESSION
H. R. 15
To amend title XVIII of the Social Security Act to improve preventive benefits
under the Medicare program.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 7, 1997
Mr. THOMAS (for himself, Mr. BILIRAKIS, and 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 sub-
sequently 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 improve
preventive benefits under the Medicare program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Medicare Preventive Benefit Improvement Act of 1997’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Screening mammography.
Sec. 3. Screening pap smear and pelvic exams.
Sec. 4. Coverage of colorectal screening.
Sec. 5. Prostate cancer screening tests.
Sec. 6. Diabetes screening benefits.
Sec. 7. Effective date.
SEC. 2. SCREENING MAMMOGRAPHY.
(a) PROVIDING ANNUAL SCREENING MAMMOGRAPHY
FOR WOMEN OVER AGE 49.—Section 1834(c)(2)(A) of
the Social Security Act (42 U.S.C. 1395m(c)(2)(A)) is
amended—
(1) in clause (iv), by striking ‘‘but under 65
years of age,’’, and
(2) by striking clause (v).
(b) WAIVER OF DEDUCTIBLE.—The first sentence of
section 1833(b) of such Act (42 U.S.C. 1395l(b)) is
amended—
(1) by striking ‘‘and’’ before ‘‘(4)’’, and
(2) by inserting before the period at the end the
following: ‘‘, and (5) such deductible shall not apply
with respect to screening mammography (as de-
scribed in section 1861(jj))’’.
(c) 
CONFORMING
AMENDMENT.—Section
1834(c)(1)(C) of such Act (42 U.S.C. 1395m(c)(1)(C)) is
amended by striking ‘‘, subject to the deductible estab-
lished under section 1833(b),’’.
SEC. 3. SCREENING PAP SMEAR AND PELVIC EXAMS.
(a) COVERAGE OF PELVIC EXAM; INCREASING FRE-
QUENCY
OF
COVERAGE
OF
PAP
SMEAR.—Section
1861(nn) of the Social Security Act (42 U.S.C.
1395x(nn)) is amended—
(1) in the heading, by striking ‘‘Smear’’ and in-
serting ‘‘Smear; Screening Pelvic Exam’’;
(2) by striking ‘‘(nn)’’ and inserting ‘‘(nn)(1)’’;
(3) by striking ‘‘3 years’’ and all that follows
and inserting ‘‘3 years, or during the preceding year
in the case of a woman described in paragraph (3).’’;
and
(4) by adding at the end the following new
paragraphs:
‘‘(2) The term ‘screening pelvic exam’ means a pelvic
examination provided to a woman if the woman involved
has not had such an examination during the preceding 3
years, or during the preceding year in the case of a woman
described in paragraph (3), and includes a clinical breast
examination.
‘‘(3) A woman described in this paragraph is a
woman who—
‘‘(A) is of childbearing age and has not had a
test described in this subsection during each of the
preceding 3 years that did not indicate the presence
of cervical cancer; or
‘‘(B) is at high risk of developing cervical can-
cer (as determined pursuant to factors identified by
the Secretary).’’.
(b) WAIVER OF DEDUCTIBLE.—The first sentence of
section 1833(b) of such Act (42 U.S.C. 1395l(b)), as
amended by section 2(b), is amended—
(1) by striking ‘‘and’’ before ‘‘(5)’’, and
(2) by inserting before the period at the end the
following: ‘‘, and (6) such deductible shall not apply
with respect to screening pap smear and screening
pelvic exam (as described in section 1861(nn))’’.
(c) 
CONFORMING
AMENDMENTS.—Sections
1861(s)(14) and 1862(a)(1)(F) of such Act (42 U.S.C.
1395x(s)(14), 1395y(a)(1)(F)) are each amended by in-
serting ‘‘and screening pelvic exam’’ after ‘‘screening pap
smear’’.
SEC. 4. COVERAGE OF COLORECTAL SCREENING.
(a) COVERAGE.—
(1) IN GENERAL.—Section 1861 of the Social
Security Act (42 U.S.C. 1395x) is amended—
(A) in subsection (s)(2)—
(i) by striking ‘‘and’’ at the end of
subparagraphs (N) and (O), and
(ii) by inserting after subparagraph
(O) the following new subparagraph:
‘‘(P) colorectal cancer screening tests (as de-
fined in subsection (oo)); and’’; and
(B) by adding at the end the following new
subsection:
‘‘Colorectal Cancer Screening Tests
‘‘(oo)(1) The term ‘colorectal cancer screening test’
means any of the following procedures furnished to an in-
dividual for the purpose of early detection of colorectal
cancer:
‘‘(A) Screening fecal-occult blood test.
‘‘(B) Screening flexible sigmoidoscopy.
‘‘(C) In the case of an individual at high risk
for colorectal cancer, screening colonoscopy.
‘‘(D) Screening barium enema, if found by the
Secretary to be an appropriate alternative to screen-
ing flexible sigmoidoscopy under subparagraph (B)
or screening colonoscopy under subparagraph (C).
‘‘(E) For years beginning after 2002, such
other procedures as the Secretary finds appropriate
for the purpose of early detection of colorectal can-
cer, taking into account changes in technology and
standards of medical practice, availability, effective-
ness, costs, and such other factors as the Secretary
considers appropriate.
‘‘(2) In paragraph (1)(C), an ‘individual at high risk
for colorectal cancer’ is an individual who, because of fam-
ily history, prior experience of cancer or precursor neo-
plastic polyps, a history of chronic digestive disease condi-
tion (including inflammatory bowel disease, Crohn’s Dis-
ease, or ulcerative colitis), the presence of any appropriate
recognized gene markers for colorectal cancer, or other
predisposing factors, faces a high risk for colorectal can-
cer.’’.
(2) DEADLINE FOR DECISION ON COVERAGE OF
SCREENING
BARIUM
ENEMA.—Not later than 2
years after the date of the enactment of this Act, the
Secretary of Health and Human Services shall issue
and publish a determination on the treatment of
screening barium enema as a colorectal cancer
screening test under section 1861(oo) of the Social
Security Act (as added by subparagraph (B)) as an
alternative 
procedure 
to 
a 
screening 
flexible
sigmoidoscopy or screening colonoscopy.
(b) FREQUENCY AND PAYMENT LIMITS.—
(1) IN GENERAL.—Section 1834 of such Act
(42 U.S.C. 1395m) is amended by inserting after
subsection (c) the following new subsection:
‘‘(d) FREQUENCY
AND
PAYMENT
LIMITS
FOR
COLORECTAL CANCER SCREENING TESTS.—
‘‘(1) 
SCREENING
FECAL-OCCULT
BLOOD
TESTS.—
‘‘(A) PAYMENT LIMIT.—In establishing fee
schedules under section 1833(h) with respect to
colorectal cancer screening tests consisting of
screening fecal-occult blood tests, except as pro-
vided by the Secretary under paragraph (4)(A),
the payment amount established for tests per-
formed—
‘‘(i) in 1998 shall not exceed $5; and
‘‘(ii) in a subsequent year, shall not
exceed the limit on the payment amount
established under this subsection for such
tests for the preceding year, adjusted by
the applicable adjustment under section
1833(h) for tests performed in such year.
‘‘(B) FREQUENCY LIMIT.—Subject to revi-
sion by the Secretary under paragraph (4)(B),
no payment may be made under this part for
colorectal cancer screening test consisting of a
screening fecal-occult blood test—
‘‘(i) if the individual is under 50 years
of age; or
‘‘(ii) if the test is performed within
the 11 months after a previous screening
fecal-occult blood test.
‘‘(2) 
SCREENING
FLEXIBLE
SIGMOIDOS
COPIES.—
‘‘(A) PAYMENT AMOUNT.—The Secretary
shall establish a payment amount under section
1848 with respect to colorectal cancer screening
tests 
consisting 
of 
screening 
flexible
sigmoidoscopies that is consistent with payment
amounts under such section for similar or relat-
ed services, except that such payment amount
shall be established without regard to sub-
section (a)(2)(A) of such section.
‘‘(B) FREQUENCY LIMIT.—Subject to revi-
sion by the Secretary under paragraph (4)(B),
no payment may be made under this part for
a colorectal cancer screening test consisting of
a screening flexible sigmoidoscopy—
‘‘(i) if the individual is under 50 years
of age; or
‘‘(ii) if the procedure is performed
within the 47 months after a previous
screening flexible sigmoidoscopy.
‘‘(3) SCREENING COLONOSCOPY FOR INDIVID-
UALS AT HIGH RISK FOR COLORECTAL CANCER.—
‘‘(A) PAYMENT AMOUNT.—The Secretary
shall establish a payment amount under section
1848 with respect to colorectal cancer screening
test consisting of a screening colonoscopy for
individuals at high risk for colorectal cancer (as
defined in section 1861(oo)(2)) that is consist-
ent with payment amounts under such section
for similar or related services, except that such
payment amount shall be established without
regard to subsection (a)(2)(A) of such section.
‘‘(B) FREQUENCY LIMIT.—Subject to revi-
sion by the Secretary under paragraph (4)(B),
no payment may be made under this part for
a colorectal cancer screening test consisting of
a screening colonoscopy for individuals at high
risk for colorectal cancer if the procedure is
performed within the 23 months after a pre-
vious screening colonoscopy.
‘‘(4) REDUCTIONS IN PAYMENT LIMIT AND RE-
VISION OF FREQUENCY.—
‘‘(A) REDUCTIONS IN PAYMENT LIMIT FOR
SCREENING
FECAL-OCCULT
BLOOD
TESTS.—
The Secretary shall review from time to time
the appropriateness of the amount of the pay-
ment limit established for screening fecal-occult
blood tests under paragraph (1)(A). The Sec-
retary may, with respect to tests performed in
a year after 2000, reduce the amount of such
limit as it applies nationally or in any area to
the amount that the Secretary estimates is re-
quired to assure that such tests of an appro-
priate quality are readily and conveniently
available during the year.
‘‘(B) REVISION OF FREQUENCY.—
‘‘(i) REVIEW.—The Secretary shall re-
view periodically the appropriate frequency
for performing colorectal cancer screening
tests based on age and such other factors
as the Secretary believes to be pertinent.
‘‘(ii) REVISION OF FREQUENCY.—The
Secretary, taking into consideration the re-
view made under clause (i), may revise
from time to time the frequency with
which such tests may be paid for under
this subsection, but no such revision shall
apply to tests performed before January 1,
2001.
‘‘(5) LIMITING CHARGES OF NONPARTICIPATING
PHYSICIANS.—
‘‘(A) IN
GENERAL.—In the case of a
colorectal cancer screening test consisting of a
screening flexible sigmoidoscopy or a screening
colonoscopy provided to an individual at high
risk for colorectal cancer for which payment
may be made under this part, if a nonpartici-
pating physician provides the procedure to an
individual enrolled under this part, the physi-
cian may not charge the individual more than
the limiting charge (as defined in section
1848(g)(2)).
‘‘(B) ENFORCEMENT.—If a physician or
supplier knowingly and willfully imposes a
charge in violation of subparagraph (A), the
Secretary may apply sanctions against such
physician or supplier in accordance with section
1842(j)(2).’’.
(2) SPECIAL
RULE
FOR
SCREENING
BARIUM
ENEMA.—If the Secretary of Health and Human
Services issues a determination under paragraph
(1)(C) that screening barium enema should be cov-
ered as a colorectal cancer screening test under sec-
tion 1861(oo) of the Social Security Act (as added
by paragraph (2)(B)), the Secretary shall establish
frequency limits (including revisions of frequency
limits) for such procedure consistent with the fre-
quency limits for other colorectal cancer screening
tests under section 1834(d) of such Act (as added
by subparagraph (A)), and shall establish payment
limits (including limits on charges of nonparticipat-
ing physicians) for such procedure consistent with
the payment limits under part B of title XVIII of
such Act for diagnostic barium enema procedures.
(c) CONFORMING AMENDMENTS.—(1) Paragraphs
(1)(D) and (2)(D) of section 1833(a) of such Act (42
U.S.C. 1395l(a)) are each amended by inserting ‘‘or sec-
tion 1834(d)(1)’’ after ‘‘subsection (h)(1)’’.
(2) 
Section 
1833(h)(1)(A) 
(42 
U.S.C.
1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’
and inserting ‘‘Subject to paragraphs (1) and (4)(A) of
section 1834(d), the Secretary’’.
(3) Clauses (i) and (ii) of section 1848(a)(2)(A) (42
U.S.C. 1395w–4(a)(2)(A)) are each amended by inserting
after ‘‘a service’’ the following: ‘‘(other than a colorectal
cancer screening test consisting of a screening colonoscopy
provided to an individual at high risk for colorectal cancer
or a screening flexible sigmoidoscopy)’’.
(4) Section 1862(a) of such Act (42 U.S.C. 1395y(a))
is amended—
(A) in paragraph (1)—
(i) in subparagraph (E), by striking ‘‘and’’
at the end,
(ii) in subparagraph (F), by striking the
semicolon at the end and inserting ‘‘, and’’, and
(iii) by adding at the end the following new
subparagraph:
‘‘(G) in the case of colorectal cancer screening
tests, which are performed more frequently than is
covered under section 1834(d);’’; and
(B) in paragraph (7), by striking ‘‘paragraph
(1)(B) or under paragraph (1)(F)’’ and inserting
‘‘subparagraph (B), (F), or (G) of paragraph (1)’’.
SEC. 5. PROSTATE CANCER SCREENING TESTS.
(a) COVERAGE.—Section 1861 of the Social Security
Act (42 U.S.C. 1395x), as amended by section 4(a), is
amended—
(1) in subsection (s)(2)—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (P);
(B) by adding ‘‘and’’ at the end of sub-
paragraph (Q); and
(C) by adding at the end the following new
subparagraph:
‘‘(R) prostate cancer screening tests (as defined
in subsection (pp)); and’’; and
(2) by adding at the end the following new sub-
section:
‘‘Prostate Cancer Screening Tests
‘‘(pp)(1) The term ‘prostate cancer screening test’
means a test that consists of any (or all) of the procedures
described in paragraph (2) provided for the purpose of
early detection of prostate cancer to a man over 50 years
of age who has not had such a test during the preceding
year.
‘‘(2) The procedures described in this paragraph are
as follows:
‘‘(A) A digital rectal examination.
‘‘(B) A prostate-specific antigen blood test.
‘‘(C) For years beginning after 2001, such
other procedures as the Secretary finds appropriate
for the purpose of early detection of prostate cancer,
taking into account changes in technology and
standards of medical practice, availability, effective-
ness, costs, and such other factors as the Secretary
considers appropriate.’’.
(b) PAYMENT
FOR PROSTATE-SPECIFIC ANTIGEN
BLOOD TEST UNDER CLINICAL DIAGNOSTIC LABORA-
TORY TEST FEE SCHEDULES.—Section 1833(h)(1)(A) of
such Act (42 U.S.C. 1395l(h)(1)(A)) is amended by in-
serting after ‘‘laboratory tests’’ the following: ‘‘(including
prostate cancer screening tests under section 1861(pp)
consisting of prostate-specific antigen blood tests)’’.
(c) CONFORMING AMENDMENT.—Section 1862(a) of
such Act (42 U.S.C. 1395y(a)), as amended by section
4(c)(4), is amended—
(1) in paragraph (1)—
(A) in subparagraph (F), by striking
‘‘and’’ at the end,
(B) in subparagraph (G), by striking the
semicolon at the end and inserting ‘‘, and’’, and
(C) by adding at the end the following new
subparagraph:
‘‘(H) in the case of prostate cancer screening
tests (as defined in section 1861(oo)), which are per-
formed more frequently than is covered under such
section;’’; and
(2) in paragraph (7), by striking ‘‘or (G)’’ and
inserting ‘‘(G), or (H)’’.
SEC. 6. DIABETES SCREENING BENEFITS.
(a) COVERAGE
OF DIABETES OUTPATIENT SELF-
MANAGEMENT TRAINING SERVICES.—
(1) IN GENERAL.—Section 1861 of the Social
Security Act (42 U.S.C. 1395x), as amended by sec-
tions 4(a) and 5(a), is amended—
(A) in subsection (s)(2)—
(i) by striking ‘‘and’’ at the end of
subparagraph (Q);
(ii) by adding ‘‘and’’ at the end of
subparagraph (R); and
(iii) by adding at the end the follow-
ing new subparagraph:
‘‘(S) diabetes outpatient self-management train-
ing services (as defined in subsection (qq)); and’’;
and
(B) by adding at the end the following new
subsection:
‘‘Diabetes Outpatient Self-management Training Services
‘‘(qq)(1) The term ‘diabetes outpatient self-manage-
ment training services’ means educational and training
services furnished to an individual with diabetes by or
under arrangements with a certified provider (as described
in paragraph (2)(A)) in an outpatient setting by an indi-
vidual or entity who meets the quality standards described
in paragraph (2)(B), but only if the physician who is man-
aging the individual’s diabetic condition certifies that such
services are needed under a comprehensive plan of care
related to the individual’s diabetic condition to provide the
individual with necessary skills and knowledge (including
skills related to the self-administration of injectable drugs)
to participate in the management of the individual’s condi-
tion.
‘‘(2) In paragraph (1)—
‘‘(A) a ‘certified provider’ is an individual or
entity that, in addition to providing diabetes out-
patient self-management training services, provides
other items or services for which payment may be
made under this title; and
‘‘(B) an individual or entity meets the quality
standards described in this paragraph if the individ-
ual or entity meets quality standards established by
the Secretary, except that the individual or entity
shall be deemed to have met such standards if the
individual or entity meets applicable standards origi-
nally established by the National Diabetes Advisory
Board and subsequently revised by organizations
who participated in the establishment of standards
by such Board, or is recognized by the American Di-
abetes Association as meeting standards for furnish-
ing the services.’’.
(2) CONSULTATION
WITH
ORGANIZATIONS
IN
ESTABLISHING
PAYMENT
AMOUNTS
FOR
SERVICES
PROVIDED BY PHYSICIANS.—In establishing payment
amounts under section 1848(a) of the Social Secu-
rity Act for physicians’ services consisting of diabe-
tes outpatient self-management training services, the
Secretary of Health and Human Services shall con-
sult with appropriate organizations, including the
American Diabetes Association, in determining the
relative value for such services under section
1848(c)(2) of such Act.
(b) BLOOD-TESTING STRIPS FOR INDIVIDUALS WITH
DIABETES.—
(1) INCLUDING STRIPS AS DURABLE MEDICAL
EQUIPMENT.—The first sentence of section 1861(n)
of such Act (42 U.S.C. 1395x(n)) is amended by in-
serting before the semicolon the following: ‘‘, and in-
cludes blood-testing strips for individuals with diabe-
tes without regard to whether the individual has
Type I or Type II diabetes or to the individual’s use
of insulin (as determined under standards estab-
lished by the Secretary in consultation with the
American Diabetes Association)’’.
(2) PAYMENT FOR STRIPS BASED ON METH-
ODOLOGY FOR INEXPENSIVE AND ROUTINELY PUR-
CHASED
EQUIPMENT.—Section 1834(a)(2)(A) of
such Act (42 U.S.C. 1395m(a)(2)(A)) is amended—
(A) by striking ‘‘or’’ at the end of clause
(ii);
(B) by adding ‘‘or’’ at the end of clause
(iii); and
(C) by inserting after clause (iii) the fol-
lowing new clause:
‘‘(iv) which is a blood-testing strip for
an individual with diabetes,’’.
(c) ESTABLISHMENT OF OUTCOME MEASURES FOR
BENEFICIARIES WITH DIABETES.—
(1) IN GENERAL.—The Secretary of Health and
Human Services, in consultation with appropriate
organizations (including the American Diabetes As-
sociation), shall establish outcome measures, includ-
ing glysolated hemoglobin (past 90-day average
blood sugar levels), for purposes of evaluating the
improvement of the health status of Medicare bene-
ficiaries with diabetes mellitus.
(2) RECOMMENDATIONS
FOR
MODIFICATIONS
TO SCREENING BENEFITS.—Taking into account in-
formation on the health status of Medicare bene-
ficiaries with diabetes mellitus as measured under
the outcome measures established under subpara-
graph (A), the Secretary shall from time to time
submit recommendations to Congress regarding
modifications to the coverage of services for such
beneficiaries under the Medicare program.
SEC. 7. EFFECTIVE DATE.
The amendments made by this Act shall apply to
items and services furnished on or after January 1, 1998.
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