A bill introduced June 16 in the Senate would give the Centers for Medicare & Medicaid Services more discretion in covering screening tests.

Co-sponsored by Sens. Bob Graham (D-Fla.) and Richard Durbin (D-Ill.), the "Medicare Preventive Services Coverage Act of 2004" (S 2535) would amend the Social Security Act, enabling HHS to make evidence-based coverage decisions for preventive services.

CMS' authority to cover certain screening tests was expanded by the Medicare Modernization Act of 2003 (¹ Also see "Lab Industry Ramping Up Heart, Diabetes Tests Covered Under Rx Bill" - Medtech Insight, 8 December, 2003., p. 10). Currently, Congress must approve each additional screening benefit for the Medicare program.

Although it is possible that CMS could expand coverage of preventive services without legislative action, the agency likely would want a congressional signal, CMS Coverage & Analysis Group Director Steve Phurrough told the HHS Secretary's Advisory Committee on Genetics, Health & Society at a June 14-15 meeting.

The group convened to discuss a June report on coverage and reimbursement of genetic technologies and services.

In the report, SACGHS singled out CMS' inability to cover tests for screening purposes as a potential barrier for reimbursement of genetic technologies (² Also see "SACGHS Plans To Develop Genetic Test Reimbursement Recommendations" - Medtech Insight, 7 June, 2004., p. 14). At the meeting, advisory group members said the point should be retained in revised versions of the document.

Phurrough told SACGHS "it has been a long-standing Medicare policy that Congress prohibits us in its language from paying for tests of a screening nature."

However, "we have had a lot of discussions in the last several months as to whether it was Congress' intention," he reported.

"There are some viewpoints that say that CMS could change its mind, without congressional input," but "even those who think that is the case, think it could only be done through rulemaking," he revealed.

While "the agency could, based on our legal authority, change some of our screening exclusions...congressional directions would be a preferable solution." Phurrough then referred to the pending legislation, observing it would "allow [CMS] to do coverage determinations on screening and preventive services."

The bill will "ensure that important preventive care services be covered in a more timely and cost-effective way," according to Graham, who describes the legislation as "getting rid of much of the red tape that goes along with providing preventive services to Medicare beneficiaries."

In a June 2 letter supporting the legislation, Partnership for Prevention charges that "Medicare has consistently lagged behind the curve, failing to cover proven disease prevention and health promotion services or providing coverage years later than private insurers."

"Allowing Medicare coverage decisions for preventive services to be made following a similar process as diagnosis and treatment decisions is an important step in modernizing Medicare," the health advocacy group writes.

The organization also stresses as "critical" that "these coverage decisions be informed by systematic review of evidence conducted by independent experts, such as the U.S. Preventive Services Task Force."

The bill explicitly references USPSTF and "other appropriate organizations" in describing what kinds of evidence-based recommendations should be used to make coverage policies.

Besides allowing CMS more latitude in making coverage decisions, the bill also amends current Medicare policy by eliminating co-payments and deductibles related to preventive services.

Among other organizations supporting the legislation are the American College of Preventive Medicine, American Public Heath Association, American Academy of Family Physicians, American Physical Therapy Association, Deafness Research Foundation and the United Cerebral Palsy Association.

The bill has been referred to the Senate Committee on Finance.

CMS Coverage Authority For Screening Tests Endorsed By Graham/Durbin

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