June 12, 2025

Dear Senator Cassidy and Chairman Crapo,

I am writing on behalf of the Complex Care Alliance (“CCA”) a collection of provider groups that participate in Medicare value-based models and serve Medicare beneficiaries with high health care needs. We were recently made aware that the Committee is considering including the No UPCODE Act (S. 1105) in the reconciliation package. We write to ensure that the definitions of “health risk assessments” are clear and do not unintentionally include appropriate care provided to the most vulnerable Medicare beneficiaries where they live.

The CCA represents accountable care organizations that partner with primary care providers who deliver care to patients with high health care needs. Many of these patients are clinically homebound, near homebound and many permanently reside in an assisted living or nursing facility. CCA members participate in traditional Medicare value-based models, as well as serve hundreds of thousands of Medicare Advantage patients. Certain members also sponsor their own Medicare Advantage special needs plans.

We support Senator Cassidy’s goal of ensuring that only accurate and clinically valid diagnoses impact risk adjustment in Medicare Advantage. We also acknowledge that there have been concerns about the accuracy of certain diagnoses that stem from HRAs. And we are interested in working with the committee and Senator Cassidy on addressing misuse of these tools for HCC coding.

However, we are concerned about S.1105 and the potential definition of “Health Risk Assessment” (HRA). As currently written, S.1105 doesn’t define what services would be considered a HRA. The only definition we are familiar with is one used by the Office of Inspector General in an October 2024 report, in which OIG identifies several codes (including CPT codes CPT 99340-99350 for home-based evaluation and management services) that are also frequently used in the delivery of longitudinal primary care for patients with complex illness. We are particularly concerned that the definition of HRA could inadvertently undermine the delivery of legitimate primary care where beneficiaries live, and also push Medicare Advantage plans to avoid patients with complex needs that may be homebound, near homebound or reside in a facility. We recommend the Committee to explicitly exclude from any HRA definition CPT 99340-99350 and “other primary care services delivered in patients’ homes” (which could include private residences or health care facilities).

A 2024 study published in the Annals of Internal Medicine found that 22% of beneficiaries in a large national Medicare Advantage plan were either homebound (8.4%) or semi-homebound (13.6%). These individuals have significant functional limitations and high care needs — precisely the kind of beneficiaries for whom accurate risk adjustment is essential to ensure continued access to high-quality care in the setting that best meets their needs.

We note that CMS shares these concerns and indicated as such in responding to recommendations from the OIG (see below). If home-based E&Ms were included in the definition of HRA and, as a result excluded from risk adjustment, MA plans would be disincentivized from enrolling clinically home-bound Medicare beneficiaries, as the diagnoses captured from their main source of outpatient – care—home-based E&M visits – would no longer contribute to their clinical risk score. Alternatively, it could drive plans to try to bring existing home-bound beneficiaries out of their home and into brick-and-mortar settings where their diagnoses could be captured, even if this is not in the beneficiary’s best interest and would not result in appropriate follow up care to address the documented diagnoses. We trust that this is not the policy’s intent. To avoid this unintended outcome, we urge you to proactively exclude primary care services delivered in the home from the statutory definition of “health risk assessments” in the legislative language.

We would be happy to discuss this with you further.

Sincerely,

Mara McDermott
CEO
Accountable for Health

Pulled from OIG Report

OIG Recommendation CMS should restrict the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments.

CMS Response CMS does not concur with this recommendation. CMS requires MA organizations to submit all diagnoses codes through encounter data, and CMS allows MA organizations to use HRAs as a source of diagnoses used for the calculation of risk adjusted payments, as long as those diagnoses meet CMS’s criteria for risk adjustment eligibility. Although OIG has expressed concern that these diagnoses may be inaccurate, they have not conducted medical record reviews of the diagnoses that came from visits that may have contained an HRA and have not concluded that these diagnoses are not accurate. Additionally, CMS believes the recommendation does not adequately address the complexities of identifying home visits where the primary purpose is for coding assessment or whether the primary purpose is for treatment. As such, the recommendation does not address how to classify different types of home visits, whether they include an in-home “health risk assessment” or not. CMS will take OIG’s recommendation under consideration as part of our ongoing process to determine policy options for future years. CMS will continue its efforts to conduct RADV audits to inform our understanding of the accuracy of these diagnoses. If CMS determines that diagnosis codes from such visits should be excluded from risk adjusted payments or that other requirements need to be met for them to be a source of diagnoses towards payment, we note that there are many important issues to address, such as whether to exclude some, and not all, in-home services as a source of diagnoses for risk adjustment. CMS believes that Medicare beneficiaries should have access to care that is appropriately provided in the home setting and we would want to take into account this consideration if we were to contemplate a policy of not using diagnoses from home visits. Since the E&M codes identified by OIG as potential HRAs can cover a wide variety of services, we would need to assess the extent to which the result may disincentivize the provision of home-based services, for example, a scenario where an enrollee is receiving treatment in the home and the provider identifies an emerging condition that should be treated. Another issue is how to identify visits that do not incorporate the use of a formal HRA, but may have the same purpose of identifying diagnoses that may not be used for follow up care, such that excluding only HRAs may not achieve what is intended.