Dear Senator Cassidy and Chairman Crapo,
On behalf of the Home Centered Care Institute (HCCI), a national non-profit committed to advancing home-based primary care for medically complex patients, I write to express our concern regarding the potential inclusion of the No UPCODE Act (S.1105) in the reconciliation package. We respectfully urge the Committee to ensure that the definition of “health risk assessments” (HRAs) is clear and does not unintentionally encompass appropriate, high-quality care provided to the most vulnerable Medicare beneficiaries in their homes.
HCCI has trained over 4,000 house call professionals and supported more than 2,000 home-based medical care practices, which have collectively delivered over 3.2 million house calls. They serve complex, high-needs patients, many of whom are clinically homebound, home-limited, or permanently reside in assisted living or nursing facilities.
We support Senator Cassidy’s goal of ensuring that only accurate and clinically valid diagnoses impact risk adjustment in Medicare Advantage (MA). We also acknowledge the concerns about the misuse of HRAs for coding purposes and are eager to collaborate with the Committee to address these issues responsibly.
However, we are concerned that S.1105, as currently written, lacks a clear definition of what constitutes an HRA. The only reference we are aware of is from the Office of Inspector General’s October 2024 report, which includes CPT codes 99340–99350—codes frequently used for home-based evaluation and management (E/M) services—as part of its HRA definition. These codes are essential for delivering longitudinal primary care to patients with complex illnesses.
If these services are included in the HRA definition and subsequently excluded from risk adjustment:
• Legitimate diagnoses captured during home-based visits would no longer contribute to risk scores, reducing the resources available to care for high-need patients.
• MA plans may be disincentivized from enrolling or adequately supporting homebound beneficiaries.
• Providers may be pressured to bring frail patients into clinics solely to capture diagnoses, even when this is medically inappropriate and potentially harmful.
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 complex 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 also note that CMS has expressed similar concerns in response to the OIG’s recommendations. If home-based E/M services are included in the HRA definition and excluded from risk adjustment, MA plans may be incentivized to avoid enrolling clinically homebound beneficiaries or to shift care to brick-and-mortar settings, even when this is not in the patient’s best interest, does not align with their wishes, and does not support appropriate follow-up care.
We trust that this is not the policy’s intent. To avoid these unintended consequences, we respectfully urge the Committee to:
• Explicitly exclude from the statutory definition of “health risk assessments”:
- CPT codes 99340–99350, and
- Other primary care services delivered in patients’ homes, including private residences and healthcare facilities.
We would welcome the opportunity to discuss this further and work collaboratively to ensure that reforms to the MA program protect access to care for the most vulnerable beneficiaries.
Julie Sacks
President & Chief Executive Officer
Home Centered Care Institute