S. 1105 – No UPCODE Act

AI-Generated Summary

Updated November 24, 2025 at 1:42 AM UTC

The No UPCODE Act changes how Medicare Advantage plans are paid by improving the risk‑adjustment system. It requires using two years of diagnostic data, excludes certain diagnoses from chart reviews and health‑risk assessments, and adds a yearly evaluation of coding differences with public reporting and payment adjustments. These changes affect Medicare Advantage plans, the Centers for Medicare & Medicaid Services, and health‑care providers that submit diagnostic information.

Key Provisions

For 2026 onward, the Secretary must use up to two years of diagnostic data (when available) when calculating Medicare Advantage risk‑adjustment payments.
Diagnoses that come from chart reviews or health‑risk assessments cannot be used to set payment adjustment factors; the Secretary must create procedures to identify and verify such diagnoses.
The Secretary must evaluate each year how differences in coding practices between Medicare Advantage plans and traditional Medicare (Parts A and B) affect risk scores, publicly report the findings, and adjust payments—potentially at the plan or contract level—to fully account for those coding differences.

Legislative Activity

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SenateIntro Referral Latest Action

Read twice and referred to the Committee on Finance.

Finance Committee

March 25, 2025

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SenateIntro Referral

Introduced in Senate

March 25, 2025

SenateIntro Referral

Read twice and referred to the Committee on Finance.

Finance Committee

March 25, 2025

Bill Text

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Introduced in SenateIssued March 25, 2025

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.

.