S. 1105 — No UPCODE Act

This section modifies risk adjustment for Medicare Advantage (MA) capitation payments under SSA §1853(a) as follows, effective for 2026 and subsequent years: (1) requires use of 2 years of diagnostic data (when available) under the risk adjustment methodology; (2) excludes diagnoses collected from chart reviews or health risk assessments when adjusting payments based on enrollee health status, with procedures for identifying and verifying such diagnoses; and (3) requires annual evaluation of coding pattern differences between MA plans and traditional Medicare (Parts A and B), public reporting of results, and ensures the coding intensity adjustment fully accounts for identified differences (potentially on a plan- or contract-specific basis). (As background, MA risk adjustment compensates plans with higher payments for enrollees with greater health risks based on submitted diagnoses; thus, these changes address concerns over MA overcoding practices that inflate risk scores relative to traditional Medicare.)