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To amend title XVIII of the Social Security Act to improve risk adjustment under Medicare Advantage.
Summary
This bill amends Medicare Advantage risk adjustment provisions to address coding practices and diagnostic data collection. Beginning in 2026, it requires the Secretary of Health and Human Services to use two years of diagnostic data when available for risk adjustment calculations instead of one year. The bill excludes diagnoses collected from chart reviews and health risk assessments from risk adjustment calculations, and requires the Secretary to establish procedures to identify and verify such diagnoses. The bill also requires annual evaluation and public reporting of the impact of coding pattern differences between Medicare Advantage plans and traditional Medicare providers, with adjustments to ensure such differences are fully accounted for in payment calculations.
AI-generated plain-language summary of the bill text — neutral, and may be imperfect. See the full text below for the exact wording.
Sponsor (1)
- Sen. Cassidy, Bill [R-LA] (R-LA)
1 cosponsor
- Sen. Merkley, Jeff [D-OR] (D-OR)
Money behind the sponsor
Top reported contributors to Bill Cassidy’s campaign committee (2024 cycle) — who funds the bill’s sponsor, not a claim about this bill. Data from FEC.
- ANDREESSEN HOROWITZ $59,100
- GENERAL ATLANTIC $37,700
- WELSH CARSON ANDERSON & STOWE $33,870
- OCHSNER HEALTH SYSTEM $33,250
- RA CAPITAL MANAGEMENT $30,200
Organizations whose employees gave the most — itemized individual contributions grouped by the donor’s reported employer (FEC Schedule A). Full finance for Bill Cassidy → · Outside spending →
Actions (2)
- Mar 25, 2025 Read twice and referred to the Committee on Finance. · senate
- Mar 25, 2025 Introduced in Senate
Similar bills (6)
Bills with similar text or summary — includes reintroductions across Congresses. Ranked by semantic similarity of the bill text (computed locally); a neutral discovery aid, not a claim the bills are duplicates.
Full text
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.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 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”.
SEC. 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.”. <all>
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