II 

118TH CONGRESS 

1ST SESSION S. 1002 

To amend title XVIII of the Social Security Act to improve risk adjustment 

under Medicare Advantage. 

IN THE SENATE OF THE UNITED STATES 

MARCH 28, 2023 

Mr. CASSIDY (for himself and Mr. MERKLEY) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to improve 

risk adjustment under Medicare Advantage. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘No Unreasonable Pay5 ments, Coding, Or Diagnoses for the Elderly Act’’ or the 

6 ‘‘No UPCODE Act’’. 


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1 SEC. 2. IMPROVING RISK ADJUSTMENT UNDER MEDICARE 

2 ADVANTAGE. 

3 (a) USE OF 2 YEARS OF DIAGNOSTIC DATA.—Sec4 tion 1853(a)(3)(C)(iii) of the Social Security Act (42 

5 U.S.C. 1395w–23(a)(3)(C)(iii)) is amended— 

6 (1) by striking ‘‘METHODOLOGY.—Such risk’’ 

7 and inserting ‘‘METHODOLOGY.— 

8 ‘‘(I) IN GENERAL.—Subject to 

9 subclause (II), such risk’’; and 

10 (2) by adding at the end the following new sub11 clauses: 

12 ‘‘(II) USE OF HEALTH STATUS

13 DATA.—For 2024 and each subse14 quent year, the Secretary shall use 2 

15 years of diagnostic data (when avail16 able) under such risk adjustment 

17 methodology.’’. 

18 (b) EXCLUSION OF DIAGNOSES COLLECTED FROM

19 CHART REVIEWS AND HEALTH RISK ASSESSMENTS.— 

20 (1) IN GENERAL.—Section 1853(a)(1)(C) of 

21 such Act (42 U.S.C. 1395w–23(a)(1)(C)) is amend22 ed by adding at the end the following new clause: 

23 ‘‘(iv) EXCLUSION OF DIAGNOSES COL24 LECTED FROM CHART REVIEWS AND

25 HEALTH RISK ASSESSMENTS.— 


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1 ‘‘(I) IN GENERAL.—For 2024 

2 and each subsequent year, for pur3 poses of establishing the payment ad4 justment factors and adjusting pay5 ment based on health status under 

6 clause (i), the Secretary shall not take 

7 into account a diagnosis collected 

8 from a chart review or a health risk 

9 assessment. 

10 ‘‘(II) IDENTIFICATION OF DIAG11 NOSES COLLECTED FROM CHART RE12 VIEWS AND HEALTH RISK ASSESS13 MENTS.—The Secretary shall estab14 lish procedures to provide for the 

15 identification and verification of diag16 noses collected from chart reviews and 

17 health risk assessments.’’. 

18 (c) APPLICATION OF CODING ADJUSTMENT.—Sec19 tion 1853(a)(1)(C)(ii) of such Act (42 U.S.C. 1395w– 

20 23(a)(1)(C)(ii)) is amended— 

21 (1) in subclause (III), by striking ‘‘In calcu22 lating’’ and inserting ‘‘Subject to subclause (V), in 

23 calculating’’; and 

24 (2) by adding at the end the following new sub25 clause: 


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1 ‘‘(V) In calculating such adjust2 ment for 2024 and each subsequent 

3 year, the Secretary shall evaluate the 

4 impact on risk scores for Medicare 

5 Advantage enrollees of differences in 

6 coding patterns between Medicare Ad7 vantage plans and providers under 

8 parts A and B and publicly report the 

9 results of such evaluation. The Sec10 retary shall ensure that such adjust11 ment, which may include adjustment 

12 on a plan or contract level, fully ac13 counts for the impact of coding pat14 tern differences not otherwise ac15 counted for to the extent that the Sec16 retary identifies such differences 

17 through annual evaluation.’’. 

Æ 


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