No UPCODE Act
Sponsored By: Senator Bill Cassidy
Introduced
Summary
Would change how Medicare Advantage risk adjustment uses diagnoses and coding patterns. Beginning in 2026 it would require CMS to use two years of diagnostic data for risk scores, bar diagnoses gathered from chart reviews and health risk assessments from being used for payment adjustments, and require annual evaluation and public reporting of coding pattern differences with adjustments to risk models that may be plan- or contract-level.
Show full summary
- Medicare Advantage enrollees: Risk scores that help determine plan payments would be calculated from two years of diagnostic data starting in 2026.
- Medicare Advantage plans: Diagnoses collected from chart reviews or health risk assessments could not be used to increase payment adjustments, and CMS would need procedures to identify and verify those diagnoses.
- Centers for Medicare & Medicaid Services and the Medicare program: CMS would have to evaluate coding pattern differences each year, publicly report the results, and adjust the risk adjustment methodology to fully account for those differences, possibly with plan- or contract-level adjustments.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 0 benefits, 0 costs, 1 mixed.
Medicare Advantage coding and payments
If enacted, the bill would require the Secretary (CMS) to use two years of diagnosis data for Medicare Advantage risk scores starting in 2026. Diagnoses found only by chart reviews or health risk assessments would not count for payment adjustments, and CMS would set procedures to identify those diagnoses. CMS would annually study and publicly report coding differences between Medicare Advantage plans and Parts A and B providers. CMS would adjust risk‑adjustment payments to fully account for identified coding differences, which could include plan- or contract-level changes. These changes could lower some plan payments and might affect benefits or premiums for Medicare Advantage enrollees.
Sponsors & CoSponsors
Sponsor
Bill Cassidy
LA • R
Cosponsors
Jeff Merkley
OR • D
Sponsored 3/25/2025
Roll Call Votes
No roll call votes available for this bill.
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