COVERAGE OF SCREENING MAMMOGRAPHY.

SEC. 4163. COVERAGE OF SCREENING MAMMOGRAPHY. (a) In General.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended— (1) in subsection (s)— (A) in paragraph (11), by striking all that follows “(bb))” and inserting a semicolon, (B) in paragraph (12)(0, by striking all that follows “area” and inserting “; and”, and (C) by inserting after paragraph (12) the following new paragraph: 104 STAT. 1388–97 “(13) screening mammography (as defined in subsection (jj));”; and (2) by inserting after subsection (ii) the following new sub-section: “Screening Mammography “(jj) The term ‘screening mammography’ means a radiologic procedure provided to a woman for the purpose of early detection of breast cancer and includes a physician’s interpretation of the results of the procedure.”. (b) Payment and Coverage.— Section 1834 of such Act (42 U.S.C. 1395m) is amended— (1) in subsection (b)(l)(B), by inserting “and subject to subsection (c)(1)(A)” after “conversion factors”, and (2) by inserting after subsection (b) the following new sub-section: “(c) Payments and Standards for Screening Mammography.— (1) In general.— Notwithstanding any other provision of this part, with respect to expenses incurred for screening mammography (as defined in section 1861(jj))— “(A) payment may be made only for screening mammography conducted consistent with the frequency permitted under paragraph (2); “(B) payment may be made only if the screening mammography meets the quality standards established under paragraph (3); and “(C) the amount of the payment under this part shall, subject to the deductible established under section 1833(b), be equal to 80 percent of the least of— “(i) the actual charge for the screening, “(ii) the fee schedule established under subsection (b) or the fee schedule established under section 1848, whichever is applicable, with respect to both the professional and technical components of the screening mammography, or “(iii) the limit established under paragraph (4) for the screening mammography. (2) Frequency covered.— “(A) In general.— Subject to revision by the Secretary under subparagraph (B)— “(i) No payment may be made under this part for screening mammography performed on a woman under 35 years of age. “(ii) Payment may be made under this part for only 1 screening mammography performed on a woman over 34 years of age, but under 40 years of age. “(iii) In the case of a woman over 39 years of age, but under 50 years of age, who— “(I) is at a high risk of developing breast cancer (as determined pursuant to factors identified by the Secretary), payment may not be made under this part for a screening mammography performed within the 11 months following the month in which a previous screening mammography was performed, or 104 STAT. 1388–98 “(II) is not at a high risk of developing breast cancer, payment may not be made under this part for a screening mammography performed within the 23 months following the month in which a previous screening mammography was performed. “(iv) In the case of a woman over 49 years of age, but under 65 years of age, payment may not be made under this part for screening mammography performed within 11 months following the month in which a previous screening mammography was performed. “(v) In the case of a woman over 64 years of age, payment may not be made for screening mammography performed within 23 months following the month in which a previous screening mammography was performed. “(B) Revision of frequency.— “(i) Review.—The Secretary, in consultation with the Director of the National Cancer Institute, shall review periodically the appropriate frequency for performing screening mammography, 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 screening mammography may be paid for under this subsection, but no such revision shall apply to screening mammography performed before January 1, 1992. “(3) Quality standards.—The Secretary shall establish standards to assure the safety and accuracy of screening mammography performed under this part. Such standards shall include the requirements that— “(A) the equipment used to perform the mammography must be specifically designed for mammography and must meet radiologic standards established by the Secretary for mammography; “(B) the mammography must be performed by an individual who— “(i) is licensed by a State to perform radiological procedures, or “(ii) is certified as qualified to perform radiological procedures by such an appropriate organization as the Secretary specifies in regulations; “(C) the results of the mammography must be interpreted by a physician— “(i) who is certified as qualified to interpret radiological procedures by such an appropriate board as the Secretary specifies in regulations, or “(ii) who is certified as qualified to interpret screening mammography procedures by such a program as the Secretary recognizes in regulation as assuring the qualifications of the individual with respect to such interpretation; and “(D) with respect to the first screening mammography performed on a woman for which payment is made under this part, there are satisfactory assurances that the results of the mammography will be placed in permanent medical records maintained with respect to the woman. 104 STAT. 1388–99 “(4) Limit.— “(A) $55, indexed.— Except as provided by the Secretary under subparagraph (B), the limit established under this paragraph— “(i) for screening mammography performed in 1991, is $55, and “(ii) for screening mammography performed in a subsequent year is the limit established under this paragraph for the preceding year increased by the percentage increase in the MEI for that subsequent Year. “(B) Reduction of limit.—The Secretary shall review from time to time the appropriateness of the amount of the limit established under this paragraph. The Secretary may, with respect to screening mammography performed in a year after 1992, 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 screening mammography of an appropriate quality is readily and conveniently available during the year. “(C) Application of limit in hospital outpatient set-ting.—The Secretary shall provide for an appropriate allocation of the limit established under this paragraph between professional and technical components in the case of hospital outpatient screening mammography (and com-parable situations) where there is a claim for professional services separate from the claim for the radiologic procedure. “(5) Limiting charges of non participating physicians.— “(A) In general.— In the case of mammography screening performed on or after January 1, 1991, for which payment is made under this subsection, if a nonparticipating physician or supplier provides the screening to an individual entitled to benefits under this part, the physician or supplier may not charge the individual more than the limiting charge (as defined in subparagraph (B), or if less, as defined in subsection (b)(5)(B) or as defined in section 1848(g)(2)). “(B) Limiting charge defined.— In subparagraph (A), the term ‘limiting charge’ means, with respect to screening mammography performed— “(i) in 1991, 125 percent of the limit established under paragraph (4), “(ii) in 1992, 120 percent of the limit established under paragraph (4), or “(iii) after 1992, 115 percent of the limit established under paragraph (4). “(C) 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).”. (c) Certification of Screening Mammography Quality Standards.— (1) Section 1863 of such Act (42 U.S.C. 1395z) is amended by inserting “or whether screening mammography meets the standards established under section 1834(c)(3),” after “1832(a)(2)(F)(i),”. 104 STAT. 1388–100 (2) The first sentence of section 1864(a) of such Act (42 U.S.C. 1395aa(a)) is amended by inserting before the period the following: “, or whether screening mammography meets the standards established under section 1834(c)(3)”. (3) Section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended by inserting “T834(c)(3),” after “1832(a)(2)(F)(i),”. (d) Conforming Amendments.— (1) Section 1838(a)(2)(E) of such Act (42 U.S.C. 13951(a)(2)(E)) is amended by inserting “, but excluding screening mammography” after “imaging services”. (2) Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended— (A) in paragraph (1)— (i) in subparagraph (A), by striking “subparagraph (B), (C), (D), or (E)” and inserting “a succeeding subparagraph”, (ii) in subparagraph (D), by striking “and” at the end, (iii) in subparagraph (E), by striking the semicolon at the end and inserting “, and”, and (iv) by adding at the end the following new subparagraph: “(F) in the case of screening mammography, which is per-formed more frequently than is covered under section 1834(c)(2) or which does not meet the standards established under section 1834(c)(3), and, in the case of screening pap smear, which is performed more frequently than is provided under section 1861(nn);”; and (B) in paragraph (7), by inserting “or under paragraph (1)(F)” after “(1)(B)”. (e) Effective Date.—The amendments made by this section shall apply to screening mammography performed on or after January 1, 1991.