[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4167 Introduced in House (IH)]

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 Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Colon Cancer Screening and 
Prevention Act''.

SEC. 2. MEDICARE COVERAGE OF COLORECTAL SCREENING.

    (a) In General.--Section 1834 of the Social Security 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 paragraph (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 revision 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 revision 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--
                            ``(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 individuals at high risk 
        for colorectal cancer.--
                    ``(A) Payment amount.--The Secretary shall 
                establish a payment amount under section 1848 with 
                respect to screening colonoscopy for individuals at 
                high risk for colorectal cancer (as determined in 
                accordance with criteria established by the Secretary) 
                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 revision by the 
                Secretary under paragraph (4)(B), no payment may be 
                made under this part for a screening colonoscopy for 
                individuals at high risk for colorectal cancer provided 
                to an individual for the purpose of early detection of 
                colon cancer if the procedure is performed within the 
                23 months after a previous screening colonoscopy.
                    ``(C) Factors considered in establishing criteria 
                for determining individuals 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 consideration family history, prior experience of 
                cancer or precursor neoplastic polyps, a history of 
                chronic digestive disease condition (including 
                inflammatory bowel disease, Crohn's Disease, or 
                ulcerative colitis), the presence of any appropriate 
                recognized gene markers for colorectal cancer, and 
                other appropriate factors.
            ``(4) Reductions in payment limit and revision of 
        frequency.--
                    ``(A) Reductions in payment limit.--The Secretary 
                shall review from time to time the appropriateness of 
                the amount of the payment limit established for 
                screening fecal-occult blood tests under paragraph 
                (1)(A). The Secretary 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 required to 
                assure that such tests of an appropriate quality are 
                readily and conveniently available during the year.
                    ``(B) Revision of frequency.--
                            ``(i) Review.--The Secretary shall review 
                        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 believes to be 
                        pertinent.
                            ``(ii) Revision of frequency.--The 
                        Secretary, taking into consideration the review 
                        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 provided 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 ``subsection (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 individual 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 detection 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 screening colonoscopy 
        provided for the purpose of early detection 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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