The No UPCODE Act would tighten how Medicare Advantage (MA) risk adjustment is calculated. Starting in 2026, it would require CMS to use two years of diagnostic data (when available) for risk adjustment, rather than relying on shorter data or possibly more limited sources. It would also exclude diagnoses that come only from chart reviews or health risk assessments from being counted toward payment adjustments, and it would require CMS to establish procedures to identify and verify such diagnoses. Additionally, the bill would require ongoing evaluation of how coding patterns differ between MA plans and traditional Part A/B providers, with public reporting and potential plan-level adjustments to ensure that risk scores reflect true health status rather than coding intensity. Overall, the aim is to reduce the impact of upcoding and align payments more closely with actual health risk.
Key Points
- 1Use of 2 years of diagnostic data for risk adjustment in MA, starting in 2026, when available.
- 2Exclusion of diagnoses obtained from chart reviews and health risk assessments from risk adjustment computations.
- 3Annual evaluation of the impact of coding differences between MA plans and providers (Part A/B), with public reporting and adjustments to risk scores as needed.
- 4Procedures to identify and verify diagnoses from chart reviews and health risk assessments.
- 5Potential plan- or contract-level adjustments to fully account for coding pattern differences identified through annual evaluation.