Us Congress Senate Bill SB1105

Us Congress 2025-2026 Regular Session

• Introduced: 3/25/25
• Refer: 3/25/25

Caption

No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act or the No UPCODE Act This bill modifies certain factors that are used to determine Medicare Advantage (MA) payments, particularly relating to health status and related data. Specifically, the bill requires the Centers for Medicare & Medicaid Services (CMS) to use two years of diagnostic data in its risk adjustment methodology for MA payments. It also prohibits the CMS from using diagnoses that are collected from chart reviews or health risk assessments when adjusting payments based on health status. The CMS must also take into account any differences in coding patterns between MA and traditional Medicare when determining MA payment adjustments.

Impact

The implications of SB1105 on state laws revolve around the Medicare framework within the Social Security Act. By mandating the use of two years of diagnostic data for risk adjustment, the bill aims to refine how Medicare Advantage plans are reimbursed based on the actual health status of their beneficiaries. This modification is expected to discourage unnecessary procedures and diagnoses intended solely to inflate payments, thereby promoting a more responsible approach to healthcare billing and service delivery in the state.

Summary

SB1105, known as the 'No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act' or the 'No UPCODE Act', seeks to amend Title XVIII of the Social Security Act aimed at improving the risk adjustment under Medicare Advantage. The bill proposes the use of health status data over a span of two years for the purpose of risk adjustment, which is designed to ensure fairer payment structures based on the health status of enrollees. The intended outcomes include enhancing equity in Medicare Advantage payments and reducing financial discrepancies that might arise from poor coding practices.

Contention

Despite the bill's objectives of improving payment integrity, it faces potential opposition regarding the exclusion of certain diagnosis metrics. Critics may argue that by not considering data collected from chart reviews and health risk assessments, the law could overlook critical health information that informs patient care. The balance of ensuring accurate risk assessment while preventing upcoding will be a focal point of discussion among stakeholders, highlighting the complexities of how medical necessity and payment systems interact.

Congress_id

119-S-1105

Policy_area

Health

Introduced_date

2025-03-25