I
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.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Colon Cancer Screen-
ing and Prevention Act’’.
SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREEN-
ING.
(a) IN GENERAL.—Section 1834 of the Social Secu-
rity Act (42 U.S.C. 1395m) is amended by inserting after
subsection (c) the following new subsection:
‘‘(d) FREQUENCY
AND
PAYMENT
LIMITS
FOR
SCREENING FECAL-OCCULT BLOOD TESTS, SCREENING
FLEXIBLE
SIGMOIDOSCOPIES, 
AND
SCREENING
COLONOSCOPY.—
‘‘(1) 
SCREENING
FECAL-OCCULT
BLOOD
TESTS.—
‘‘(A) PAYMENT LIMIT.—In establishing fee
schedules under section 1833(h) with respect to
screening fecal-occult blood tests provided for
the purpose of early detection of colon cancer,
except as provided by the Secretary under para-
graph (3)(A), the payment amount established
for tests performed—
‘‘(i) in 1995 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 (3)(B),
no payment may be made under this part for
a screening fecal-occult blood test provided to
an individual for the purpose of early detection
of colon cancer—
‘‘(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
SIGMOID-
OSCOPIES.—
‘‘(A) PAYMENT AMOUNT.—The Secretary
shall establish a payment amount under section
1848 
with 
respect 
to 
screening 
flexible
sigmoidoscopies provided for the purpose of
early detection of colon cancer that is consistent
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 screening flexible sigmoidoscopy provided to
an individual for the purpose of early detection
of colon cancer—
cancer if the procedure is performed within the
months 
after 
a 
previous 
screening
colonoscopy.
‘‘(C) FACTORS
CONSIDERED
IN
ESTAB-
LISHING CRITERIA FOR DETERMINING INDIVID-
UALS AT HIGH RISK.—In establishing criteria
for determining whether an individual is at high
risk for colorectal cancer for purposes of this
paragraph, the Secretary shall take into consid-
eration family history, prior experience of can-
cer or precursor neoplastic polyps, a history of
chronic digestive disease condition (including in-
flammatory bowel disease, Crohn’s Disease, or
ulcerative colitis), the presence of any appro-
priate recognized gene markers for colorectal
cancer, and other appropriate factors.
‘‘(4) REDUCTIONS IN PAYMENT LIMIT AND RE-
VISION OF FREQUENCY.—
‘‘(A) REDUCTIONS IN PAYMENT LIMIT.—
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 1997, 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 screening fecal-occult blood
tests, screening flexible sigmoidoscopies,
and screening colonoscopy based on age
and such other factors as the Secretary be-
lieves 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 and procedures may be
paid for under this subsection, but no such
revision shall apply to tests or procedures
performed before January 1, 1998.
‘‘(5) LIMITING CHARGES OF NONPARTICIPATING
PHYSICIANS.—
‘‘(A) IN
GENERAL.—In the case of a
screening flexible sigmoidoscopy provided to an
individual for the purpose of early detection of
colon cancer or a screening colonoscopy pro-
vided to an individual at high risk for colorectal
cancer for the purpose of early detection of
colon cancer for which payment may be made
under this part, if a nonparticipating physician
provides the procedure to an individual enrolled
under this part, the physician may not charge
the individual more than the limiting charge (as
defined in section 1848(g)(2)).
‘‘(B) ENFORCEMENT.—If a physician or
supplier knowing 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).’’.
(b) 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 striking ‘‘sub-
section (h)(1),’’ and inserting ‘‘subsection (h)(1) or section
1834(d)(1),’’.
(2) Section 1833(h)(1)(A) of such Act (42 U.S.C.
1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’
and inserting ‘‘Subject to paragraphs (1) and (3)(A) of
section 1834(d), the Secretary’’.
(3) Clauses (i) and (ii) of section 1848(a)(2)(A) of
such Act (42 U.S.C. 1395w–4(a)(2)(A)) are each amended
by striking ‘‘a service’’ and inserting ‘‘a service (other
than a screening flexible sigmoidoscopy provided to an in-
dividual for the purpose of early detection of colon cancer
or a screening colonoscopy provided to an individual at
high risk for colorectal cancer for the purpose of early de-
tection of colon cancer)’’.
(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 screening fecal-occult blood
tests, screening flexible sigmoidoscopies, and screen-
ing colonoscopy provided for the purpose of early de-
tection of colon cancer, 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
‘‘subparagraphs (B), (F), or (G) of paragraph (1)’’.
SEC. 3. EFFECTIVE DATE.
The amendments made by section 2 shall apply to
screening fecal-occult blood tests, screening flexible
sigmoidoscopies, and screening colonoscopy performed on
or after January 1, 1995.
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