No UPCODE Act

Bill: 119-s-1105
Sponsor: full_name: Sen. Cassidy, Bill [R-LA]
Introduced: 2025-03-25
Policy area: Health
Latest action: action_date: 2025-03-25
text: Read twice and referred to the Committee on Finance.

Summaries:
action_date: 2025-03-25
action_desc: Introduced in Senate
text: <p><b>No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act or the No UPCODE Act</b></p> <p>This bill modifies certain factors that are used to determine Medicare Advantage (MA) payments, particularly relating to health status and related data. </p> <p>Specifically, the bill requires the Centers for Medicare &amp; Medicaid Services (CMS) to use two years of diagnostic data in its risk adjustment methodology for MA payments. It also prohibits the CMS from using diagnoses that are collected from chart reviews or health risk assessments when adjusting payments based on health status. The CMS must also take into account any differences in coding patterns between MA and traditional Medicare when determining MA payment adjustments.</p>

tv_txt: II 119th CONGRESS 1st Session S. 1105 IN THE SENATE OF THE UNITED STATES March 25, 2025 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. Short title This Act may be cited as the No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act or the No UPCODE Act . 2. Improving risk adjustment under Medicare Advantage (a) Use of 2 years of diagnostic data Section 1853(a)(3)(C)(iii) of the Social Security Act ( 42 U.S.C. 1395w–23(a)(3)(C)(iii) ) is amended— (1) by striking methodology .—Such risk and inserting “ methodology .— (I) In general Subject to subclause (II), such risk ; and (2) by adding at the end the following new subclauses: (II) Use of health status data For 2026 and each subsequent year, the Secretary shall use 2 years of diagnostic data (when available) under such risk adjustment methodology. . (b) Exclusion of diagnoses collected from chart reviews and health risk assessments (1) In general Section 1853(a)(1)(C) of such Act ( 42 U.S.C. 1395w–23(a)(1)(C) ) is amended by adding at the end the following new clause: (iv) Exclusion of diagnoses collected from chart reviews and health risk assessments (I) In general For 2026 and each subsequent year, for purposes of establishing the payment adjustment factors and adjusting payment based on health status under clause (i), the Secretary shall not take into account a diagnosis collected from a chart review or a health risk assessment. (II) Identification of diagnoses collected from chart reviews and health risk assessments The Secretary shall establish procedures to provide for the identification and verification of diagnoses collected from chart reviews and health risk assessments. . (c) Application of coding adjustment Section 1853(a)(1)(C)(ii) of such Act ( 42 U.S.C. 1395w–23(a)(1)(C)(ii) ) is amended— (1) in subclause (III), by striking In calculating and inserting Subject to subclause (V), in calculating ; and (2) by adding at the end the following new subclause: (V) In calculating such adjustment for 2026 and each subsequent year, the Secretary shall evaluate the impact on risk scores for Medicare Advantage enrollees of differences in coding patterns between Medicare Advantage plans and providers under parts A and B and publicly report the results of such evaluation. The Secretary shall ensure that such adjustment, which may include adjustment on a plan or contract level, fully accounts for the impact of coding pattern differences not otherwise accounted for to the extent that the Secretary identifies such differences through annual evaluation. .