119 S1105 IS: No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act U.S. Senate 2025-03-25 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.

II119th CONGRESS1st SessionS. 1105IN THE SENATE OF THE UNITED STATESMarch 25, 2025Mr. Cassidy (for himself and Mr. Merkley) introduced the following bill; which was read twice and referred to the Committee on FinanceA BILLTo 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..