What This Bill Does
This bill changes how Medicare Advantage plans (private insurance plans for people age 65 and older) receive payments from the federal government. The bill aims to improve "risk adjustment," which is the system that pays plans different amounts based on how sick their patients are.
Who It Affects
Medicare Advantage plans and the elderly people enrolled in them. The federal government's Centers for Medicare and Medicaid Services, which runs this program.
Key Provisions
• The Secretary of Health and Human Services must use 2 years of diagnostic data (health condition records) when available to calculate risk adjustment payments starting in 2024. (Sec. 2(a))
• Starting in 2024, the Secretary cannot count diagnoses that come from chart reviews (reviewing patient medical records) or health risk assessments (surveys asking patients about their health) when determining payment adjustments. (Sec. 2(b))
• The Secretary must create procedures to identify and verify which diagnoses came from chart reviews and health risk assessments. (Sec. 2(b))
• Starting in 2024, the Secretary must measure how coding pattern differences (variations in how diagnoses are recorded) between Medicare Advantage plans and traditional Medicare providers affect patient risk scores and publicly report the findings. (Sec. 2(c))
• The Secretary must ensure payment adjustments fully account for coding pattern differences identified through yearly evaluations. (Sec. 2(c))
What Changes
If this bill becomes law, Medicare Advantage payment calculations will use more years of patient health data and exclude diagnoses from certain sources. The federal government will also have to evaluate and report on coding differences between Medicare Advantage and traditional Medicare.
Important Definitions
None defined in bill text.
II
118TH CONGRESS
1ST SESSION
S. 1002
To amend title XVIII of the Social Security Act to improve risk adjustment
under Medicare Advantage.
IN THE SENATE OF THE UNITED STATES
MARCH 28, 2023
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 Representa-
1
tives of the United States of America in Congress assembled,
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SECTION 1. SHORT TITLE.
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This Act may be cited as the ‘‘No Unreasonable Pay-
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ments, Coding, Or Diagnoses for the Elderly Act’’ or the
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‘‘No UPCODE Act’’.
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•S 1002 IS
SEC. 2. IMPROVING RISK ADJUSTMENT UNDER MEDICARE
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ADVANTAGE.
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(a) USE OF 2 YEARS OF DIAGNOSTIC DATA.—Sec-
3
tion 1853(a)(3)(C)(iii) of the Social Security Act (42
4
U.S.C. 1395w–23(a)(3)(C)(iii)) is amended—
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(1) by striking ‘‘METHODOLOGY.—Such risk’’
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and inserting ‘‘METHODOLOGY.—
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‘‘(I) IN
GENERAL.—Subject to
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subclause (II), such risk’’; and
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(2) by adding at the end the following new sub-
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clauses:
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‘‘(II) USE
OF
HEALTH
STATUS
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DATA.—For 2024 and each subse-
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quent year, the Secretary shall use 2
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years of diagnostic data (when avail-
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able) under such risk adjustment
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methodology.’’.
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(b) EXCLUSION OF DIAGNOSES COLLECTED FROM
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CHART REVIEWS AND HEALTH RISK ASSESSMENTS.—
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(1) IN
GENERAL.—Section 1853(a)(1)(C) of
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such Act (42 U.S.C. 1395w–23(a)(1)(C)) is amend-
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ed by adding at the end the following new clause:
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‘‘(iv) EXCLUSION OF DIAGNOSES COL-
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LECTED
FROM
CHART
REVIEWS
AND
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HEALTH RISK ASSESSMENTS.—
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•S 1002 IS
‘‘(I) IN
GENERAL.—For 2024
1
and each subsequent year, for pur-
2
poses of establishing the payment ad-
3
justment factors and adjusting pay-
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ment based on health status under
5
clause (i), the Secretary shall not take
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into account a diagnosis collected
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from a chart review or a health risk
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assessment.
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‘‘(II) IDENTIFICATION OF DIAG-
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NOSES COLLECTED FROM CHART RE-
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VIEWS
AND
HEALTH
RISK
ASSESS-
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MENTS.—The Secretary shall estab-
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lish procedures to provide for the
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identification and verification of diag-
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noses collected from chart reviews and
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health risk assessments.’’.
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(c) APPLICATION OF CODING ADJUSTMENT.—Sec-
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tion 1853(a)(1)(C)(ii) of such Act (42 U.S.C. 1395w–
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23(a)(1)(C)(ii)) is amended—
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(1) in subclause (III), by striking ‘‘In calcu-
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lating’’ and inserting ‘‘Subject to subclause (V), in
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calculating’’; and
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(2) by adding at the end the following new sub-
24
clause:
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•S 1002 IS
‘‘(V) In calculating such adjust-
1
ment for 2024 and each subsequent
2
year, the Secretary shall evaluate the
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impact on risk scores for Medicare
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Advantage enrollees of differences in
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coding patterns between Medicare Ad-
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vantage plans and providers under
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parts A and B and publicly report the
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results of such evaluation. The Sec-
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retary shall ensure that such adjust-
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ment, which may include adjustment
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on a plan or contract level, fully ac-
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counts for the impact of coding pat-
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tern differences not otherwise ac-
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counted for to the extent that the Sec-
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retary
identifies
such
differences
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through annual evaluation.’’.
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Æ
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