[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 15 Introduced in House (IH)]

  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 
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 improve preventive 
                  benefits under 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; 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 described 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 established under section 1833(b),''.

SEC. 3. SCREENING PAP SMEAR AND PELVIC EXAMS.

    (a) Coverage of Pelvic Exam; Increasing Frequency 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 inserting 
        ``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 cancer (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 inserting ``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 defined 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 individual 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 screening 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 cancer, taking into account changes in 
        technology and standards of medical practice, availability, 
        effectiveness, 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 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, or other 
predisposing factors, faces a high risk for colorectal cancer.''.
            (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 provided by the Secretary under 
                paragraph (4)(A), the payment amount established for 
                tests performed--
                            ``(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 revision 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 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 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 individuals 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 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 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 
                previous screening colonoscopy.
            ``(4) Reductions in payment limit and revision 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 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 2000, 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 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 review 
                        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 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 
                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 
        covered as a colorectal cancer screening test under section 
        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 frequency 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 nonparticipating 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 section 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 subparagraph 
                (P);
                    (B) by adding ``and'' at the end of subparagraph 
                (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 subsection:

                   ``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, 
        effectiveness, costs, and such other factors as the Secretary 
        considers appropriate.''.
    (b) Payment for Prostate-specific Antigen Blood Test Under Clinical 
Diagnostic Laboratory Test Fee Schedules.--Section 1833(h)(1)(A) of 
such Act (42 U.S.C. 1395l(h)(1)(A)) is amended by inserting 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 performed 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 sections 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 following 
                        new subparagraph:
            ``(S) diabetes outpatient self-management training 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-management 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 individual or entity who meets the quality standards described in 
paragraph (2)(B), but only if the physician who is managing 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 condition.
    ``(2) In paragraph (1)--
            ``(A) a `certified provider' is an individual or entity 
        that, in addition to providing diabetes outpatient 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 individual 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 
        originally 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 Diabetes Association as meeting standards for 
        furnishing 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 Security 
        Act for physicians' services consisting of diabetes outpatient 
        self-management training services, the Secretary of Health and 
        Human Services shall consult 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 inserting before the semicolon the 
        following: ``, and includes blood-testing strips for 
        individuals with diabetes 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 
        established by the Secretary in consultation with the American 
        Diabetes Association)''.
            (2) Payment for strips based on methodology for inexpensive 
        and routinely purchased 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 following 
                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 Association), shall establish 
        outcome measures, including glysolated hemoglobin (past 90-day 
        average blood sugar levels), for purposes of evaluating the 
        improvement of the health status of Medicare beneficiaries with 
        diabetes mellitus.
            (2) Recommendations for modifications to screening 
        benefits.--Taking into account information on the health status 
        of Medicare beneficiaries with diabetes mellitus as measured 
        under the outcome measures established under subparagraph (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.
                                 <all>