New 'No UPCODE' Act Tightens Medicare Advantage Payments, Bans Use of Chart Reviews for Higher Rates Starting 2026

This legislation, officially named the No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act—or the No UPCODE Act—is a major shakeup for how Medicare Advantage (MA) plans get paid. Starting in 2026, the government is changing the math used to calculate payments based on how sick a plan’s members are, which is known as risk adjustment. The core idea is to make sure plans are paid fairly for the health of their members, but without rewarding them for aggressive paperwork.

The Health History Check: Two Years Are Better Than One

Currently, when the government calculates a plan’s risk score—which dictates how much they get paid—they look at one year of diagnostic data. Under this new bill, the Secretary must switch to using two full years of diagnostic data when setting the payment adjustment factors. Why does this matter? It means the payment calculation will rely on a more stable, longitudinal view of a member’s health, rather than just a snapshot from the previous year. For the average person, this should lead to more accurate, less volatile payments, which is good for the system’s stability.

Banning the Paperwork Bump

This is the part that will really hit the insurance companies. Also starting in 2026, MA plans will no longer be able to use diagnoses gathered specifically from chart reviews or health risk assessments (HRAs) to increase their risk scores and, consequently, their payments. Think of chart reviews as the plan digging through old medical records to find conditions that weren't reported in a standard visit. HRAs are often questionnaires filled out by members. These methods have been criticized for potentially leading to ‘upcoding’—getting paid more without necessarily providing more care. The bill essentially says, if a diagnosis didn't come from a standard clinical encounter that was billed to Medicare, it can’t be used to justify a higher payment. This change aims to curb what some see as administrative gaming of the system, ensuring payments reflect actual clinical encounters and care delivered.

Leveling the Coding Field

The third major piece addresses the difference in how MA plans code patient conditions versus how traditional Medicare (Parts A and B) providers code them. The bill requires the government to analyze these differences and publicly report on whether MA plans have different billing patterns that unfairly affect risk scores. Crucially, the Secretary must then adjust payments to fully account for these coding differences. This means if MA plans are found to be coding conditions differently—and perhaps inflating their risk scores relative to traditional Medicare—the government must adjust their payments down to achieve parity. This provision is complex and gives the Secretary a lot of power to define how these differences are measured and corrected, potentially leading to specific payment adjustments for individual plans. If done right, this could ensure taxpayer dollars are spent more efficiently, but the process of implementation could be a bureaucratic headache for everyone involved.