[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 1105 Introduced in Senate (IS)]

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119th CONGRESS
  1st Session
                                S. 1105

    To amend title XVIII of the Social Security Act to improve risk 
                  adjustment under Medicare Advantage.


_______________________________________________________________________


                   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.''.
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