[Federal Register Volume 63, Number 43 (Thursday, March 5, 1998)]
[Notices]
[Pages 10921-10927]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-5234]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[HCFA-1103-GN]
Medicare Program; HCFA Market Research for Providers and Other
Partners
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: General notice with comment period.
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SUMMARY: This notice seeks public comments on information needs of
Medicare risk contract health maintenance organizations (HMOs) and
competitive medical plans (CMPs) and communication strategies that
could improve the effectiveness and efficiency of the risk contract
program. Under section 4002 of the Balanced Budget Act of 1997, and
with the implementation of the Medicare+Choice program, all HMOs and
CMPs will contract with HFCA under requirements of the Medicare+Choice
program. The information sought in this notice will facilitate future
changes in the contracting program, as well as improve information
needs and communication strategies under the current risk program.
Respondents should prioritize issues raised in the preliminary research
and identify any additional areas of information needs and best
communication strategies.
This initiative is one component of our overall effort to develop a
comprehensive communication strategy with Medicare providers and HMOs/
CMPs and to develop innovative approaches that will assist all program
participants to obtain and use information in the most accessible and
effective manner. Preliminary research on the information needs of
Medicare risk contract HMOs and CMPs and effective communication
strategies has identified a number of areas in which we could provide
additional information and potential strategies for communicating that
information effectively.
DATES: Written comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on May 4,
1998.
ADDRESSES: Mail written comments (one original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-1103-GN, P.O. Box 26676,
Baltimore, MD 21207.
If you prefer, you may deliver your written comments (one original
and three copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW,
Washington, DC 20201, or
Room C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code HCFA-1103-GN. Comments received timely will be available
for public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 309-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7890).
Comments may also be submitted electronically to the following e-
mail address: [email protected]. E-mail comments must include the
full name and address of the sender and must be submitted to the
referenced address in order to be considered. All comments must be
incorporated in the e-mail message because we may not be able to access
attachments. Electronically submitted comments will also be available
for public inspection at the Independence Avenue address above.
FOR FURTHER INFORMATION CONTACT: Sherry Terrell (410) 786-6601.
SUPPLEMENTARY INFORMATION:
I. Background
Section 1876 of the Social Security Act (the Act) authorizes
Medicare payment to health maintenance organizations (HMOs) and
competitive medical plans (CMPs) that contract with HCFA to furnish
covered services to Medicare beneficiaries. For purposes of
[[Page 10922]]
this notice the term HMO includes both CMPs and HMOs. To apply for and
be approved to operate as a Medicare risk contractor, HMOs must be
licensed in the State in which they operate and have at least 5,000
commercial members. Most HMOs that have applied for Medicare contracts
have at least several years of experience managing commercial
enrollments and existing operational systems in place. Even for HMOs
with many years of experience, however, applying for a Medicare risk
contract may require substantial investments of staff time and
significant costs. Our requirements for participation, the extent of
our oversight of risk contracts, and ongoing interaction between the
HMO and HCFA are generally much greater than HMOs experience in
obtaining and maintaining State licensure and in serving commercial
clients.
Because of these different requirements, information and
communication processes between the HMO and HCFA are an important
component of the Medicare risk contracting program. HMOs that are
applying for Medicare risk contracts need information and guidance in
understanding our requirements in order to ensure that their
operational systems and approach to Medicare contracting meets those
requirements. Once approved and operational, risk contract HMOs have
ongoing needs for information and communication with us in order to
operate successfully and to remain in compliance with our standards.
Our information comes from a number of different sources, including
Peer Review Organizations (PROs) and other contractors, who are
responsible for specific operational functions.
HMOs are responsible for obtaining, understanding, and integrating
into their operations the information available from all these sources
and for seeking clarification of specific aspects of the risk contract
process, when necessary. Table 1 summarizes the major areas of
responsibility for providing information and ongoing communication with
risk contract HMOs for each of these information sources.
Table 1.--HCFA Information Sources
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Source Information responsibility
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HCFA Central Office.......... Legal, regulatory, and financial issues.
Payment Process.
Accretion/Deletion Process.
Application.
Site Visit.
HCFA Regional Office......... Operational requirements/review.
Review marketing materials and other
beneficiary communications.
Monitoring site visits and follow-up
retroactive enrollments.
Peer Review Organizations.... Communications on cooperative quality
improvement projects.
Investigation and follow-up of
beneficiary complaints and non-coverage
notices.
Other Contractors Coverage decisions (for example, local
Intermediaries and Carriers. carriers medical review policies).
Payment rates for out-of-area services.
CHDR......................... Health dispute resolution.
NCQA......................... Receive HEDIS.
ACR Review................... Review completeness ACR submission.
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II. The Application Process
Undertaking a Medicare risk contract requires that HMOs address a
number of issues that are different from their commercial enrollment
and service delivery processes. The differences between the experience
of HMOs in operating a commercial HMO based on employer contracts and
the requirements for a Medicare risk contract makes it likely that an
HMO beginning the Medicare risk application process will obtain
assistance from some source that has prior experience in Medicare risk
contracting. For HMOs that are part of a national chain that has other
Medicare risk contracts, that experience may come from a group in the
corporate office of the chain. Other HMOs may hire an individual with
prior Medicare risk contract experience to lead the application and
implementation processes. Many HMOs hire consulting firms with Medicare
risk contract experience to guide them through the process of applying
and to assist in preparation of the application.
If requested, we will provide information to clarify requirements.
Establishing the correct lines of communication early in the process is
essential to the HMO's ability to develop a successful Medicare
application.
A. Ongoing Operations
Once we have approved the application submitted by the HMO,
implementation and ongoing operations of the Medicare risk plan
requires continuing interaction and information exchange between the
HMO and HCFA. We have specific responsibilities with respect to
communication with the HMO. We delegate some of our responsibilities
for quality assurance to PROs that work directly with the HMOs. We also
use contractors to handle some functions; for example, we contract for
Adjusted Community Rating (ACR) review services and this contractor
deals directly with each HMO to obtain information and clarify
submissions before completing a preliminary review and forwarding the
ACR submissions to us for approval. In addition, HMOs require
information from intermediaries and carriers to coordinate coverage
decisions and to pay out-of-area providers. HMOs also must work with
the Center for Health Dispute Resolution (CHDR) on reconsideration.
The operational Medicare risk HMO maintains close communication
with us on an ongoing or periodic basis for the following functions and
requirements:
Marketing Materials and Plans. The HMO must obtain advance
approval of any materials that will be used to market to, or
communicate with, Medicare beneficiaries.
Enrollment and Disenrollment. The HMO submits monthly
lists of new enrollees and disenrolled members to our data system
either directly or through a contractor (for example, CompuServe) that
we use to determine payment. Discrepancies require resolution that
involve interaction between the HMO and HCFA.
Quality Assurance. The HMO must provide information to
HCFA Central and Regional Offices and may
[[Page 10923]]
participate in quality assurance and quality improvement initiatives
that we have developed with the designated PRO in its area. Beginning
in 1997, HMOs must provide HEDIS data to us, through our
contractor, the National Committee for Quality Assurance (NCQA); and
participate in the Consumers Assessments of Health Plans Study (CAHPS)
survey of Medicare beneficiaries. Working with the HMO staff, the PRO
also follows up with HMO member complaints, grievances, and appeals. We
can also request corrective action plans for quality related issues and
monitor compliance.
Financial. Annually, the HMO must prepare financial
projections and analyses to support the benefit package and premiums
that will be offered to Medicare beneficiaries. We currently use a
contractor to initiate the ACR review process and to work with the HMOs
to clarify components of the HMO's submission. Our final review and
approval process may involve further requests for information and
clarification.
New Regulations and Changes in Regulations. We develop new
regulations based on legislation and make revisions in existing
regulations. In some cases, the HMOs are asked to provide information
necessary for the development of new regulations and to provide data,
information, or comments on these regulations while in the
developmental stage. The final regulation is then published in the
Federal Register. If necessary, we may provide clarification and
elaboration of the intent and operational implications of the new
regulation.
Ongoing Monitoring and Reporting. Medicare HMOs are
responsible for regular reporting to us. Site visits to each HMO are
conducted bi-annually by our staff. The site visits are comprehensive
in nature and normally include review of every operational area of the
HMO. Following the site visit, we notify the HMO of any areas in which
deficiencies were identified and ask it to prepare a corrective action
plan. We will provide direction to other entities with which the HMOs
communicate.
B. Preliminary Research
In discussions with several Medicare risk contract HMOs, PROs, and
others, we have identified a preliminary list of information needs that
are not currently being fully met. These information items are
summarized in Table 2 for HMOs in the application process and in Table
3 for operational Medicare risk contract HMOs.
Table 2.--Additional Information That Would be Useful During the
Application Period
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A. Basic information on HCFA manuals;
Medicare and operational Operational Policy Letters
information on risk (OPLs);
contracting, including-- Transmittal Letters;
Guidelines and regulations, such
as National Marketing Guidelines, and
Physician Incentive Plan regulations.
Organizational structure of
HCFA.
Informing applicants of the
duration of the application review
process and providing a contact person
for the review.
Informing applicants when there
is a delay in the process, and of the
reason for the delay.
B. Sources of information, Published documents, with a
including: brief description of contents, and
instructions on how to obtain them and;
Names of contacts, by
operational area, with e-mail addresses
and telephone numbers.
C. Information and data, Medicare utilization statistics,
including: by geographic area;
Information on studies conducted
by, or supported by, HCFA on managed
care quality, outcomes, utilization
patterns, special population needs, and
``best practices'';
Results of quality of care
studies and outcomes surveys, by area of
country and type of facility;
Quality measurement by hospital
and skilled nursing facility (SNF), to
assist in recruiting quality facilities
for the provider networks;
Regulations affecting HMOs,
hospitals, physicians, and other
providers;
Listings of Diagnosis-Related
Group (DRG)-exempt facilities; and,
Physician fee schedules and DRG
payment rates for hospitals.
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Table 3.--Information Wanted/Needed by Medicare Risk Contractor HMOs
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A. Upon Contract Award:
Operational Information.. Provide a basic package of
materials (interviewees suggested that
this occur during the application
process).
Provide written advice on key
set-up issues, such as expected
interactions with PROs, CHDR, local
carriers and intermediaries;
availability of use of MCCOY,
CompuServe, and/or Litton; systems and
reporting requirements and the format in
which they must be provided.
B. Operational Information:
1. Carrier and Provide clearer examples of what
Intermediary. services and procedures are covered, as
determined by local carriers and fiscal
intermediaries, especially for
controversial medical areas.
Provide appropriate local
prevailing physician Medicare fee
schedules to determine reimbursement of
out-of-area care.
2. Accretion and Deletion Provide a complete and accurate
Process. listing of codes used in reports, such
as Reply Listings and Exception Detail;
include accurate and current
institutional status code on Special
Reply.
Label cumulative 6-month report
with start and end dates and disseminate
the anticipated release schedule.
Enable Litton/CompuServe to
provide corrected information with the
list of errors. Presently, HMOs have to
look up the information although Litton/
CompuServe have the information
available.
Develop industry standards and
methodology for calculation of voluntary
disenrollment rates.
Summarize changes made in
manuals given to plans on an annual
basis.
3. Marketing............. Inform HMOs on a regular basis
on the status of marketing materials in
the review process.
[[Page 10924]]
4. ACR Process........... Provide detailed information on
the ACR review process, including
delineation of rationale for steps and
the detail behind each step.
Provide the methodology for how
study factors are derived.
Provide a description of how
capitation rates are developed and
calculated.
Proved explicit instructions up-
front on the information HMOs must
submit, including the information
requirements of reviewers.
Provide explicit directions for
how ACR information should be formatted
(for example, using LOTUS-DOS).
Provide acceptable and
unacceptable data sources and
methodologies.
Publish alternative
``recommended'' studies.
Provide guidelines for Medicare
risk point of service premium
calculations.
Provide national demographic
cost factors for utilization in the APR.
Inform HMOs on a regular basis
of the status of ACR submissions in the
review process.
5. Quality Improvement Release benchmark data (for
(QI). example, congestive heart failure and
percentage of Medicare beneficiaries on
ACE inhibitors) and access measures (for
example, sentinel events, such as
inpatient admission that should not
occur if quality ambulatory care is
provided).
Provide, under the
HEDIS 3.0 (Health Plan
Employer Data and Information Set),
information to HMOs.
Develop clearer standards and
reviewer guidelines for Quality
Improvement studies.
Disseminate CHDR and Beneficiary
Information Tracking System (BITS)
reports to all plans.
6. Other................. Provide information on our
organizational structure and key
contacts, by operational area, with e-
mail addresses and telephone numbers.
Provide information on
conferences where staff are scheduled to
discuss specific issues.
Provide information about
activities and new initiatives such as
the Reengineering Application and
Monitoring (RAM) initiative on an on-
going basis.
Inform HMOs when staff will be
out of the office, and identify a back-
up person in his or her absence.
Provide guidelines for
coordination of dual eligibles and how
best to serve the special needs
populations.
Disseminate to HMOs any
information disseminated to other
participants in Medicare risk program,
for example, hospitals, physicians,
beneficiaries.
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A number of information process issues have also been identified in
these limited preliminary discussions. Process issues relate to
timeliness and completeness of information that we provide to Medicare
risk contract HMOs and to consistency of the information provided. A
summary of process issues raised in these preliminary discussions is
provided in Table 4.
Table 4.--Information Process Issues and Suggestions Raised by HMOs and
Other Interviewees
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A. Updated and Revised HCFA
Materials:
Revised, updated, and indexed
HMO/CMP Manual.
Revise applications to
explicitly state requirements.
Establish clean copies of
background materials; update as
necessary; and tab.
B. Improve Timeliness of
Communications Relative to
HMO Operational
Requirements:
1. Accretion and Deletion Improve timeliness and accuracy
Issues. of information and data exchanged
between Social Security Administration,
HCFA, and authorized vendors.
Improve timeliness, accuracy,
and exchange of data used to determine
specific categories of beneficiaries.
Review Reply Listing and
Exception Detail codes for accuracy,
currency, and completeness prior to
disseminating.
Change timing of Reply Listing
to be 1 week earlier.
Disseminate DRG tape timely.
Communicate changes affecting
Medicare claims process timely;
summarize changes in one place.
2. Payment Issues........ Inform HMOs as soon as an
overpayment or underpayment is
discovered or suspected.
3. Dissemination of Disseminate OPLs as we release
Operational Policy or receive them.
Letters (OPLs).
4. Timeliness of Allow sufficient time for HMOs
Communications and to implement changes in operational
Responses. procedures and information systems when
issuing policies, regulations, and/or
guidelines.
Strive to have structure in
place prior to implementation of
polices, regulations, and/or guidelines.
Provide information to HMOs, at
regular intervals, as new approaches are
being developed.
Schedule the Annual Renewal
Process earlier in the year.
5. HMOs' Ability to Reach Provide to HMOs a list of staff
HCFA Staff. who have specific responsibility for
specific HMO related functions and
issues.
Establish standards for
timeliness of response.
Increase the number of staff or
streamline communication process and
information transmittal mechanisms to
improve timeliness of response.
6. Bi-Annual Review...... Allow sufficient time for HMOs
to implement corrective action plan, to
demonstrate change, prior to re-
auditing.
C. Consistency and
Coordination:
Assign to the HMO a specific
contact person to coordinate all
activities and to provide clarification
to questions and problems.
Assign specific staff to resolve
inquiries and problems related to their
specific topic areas.
[[Page 10925]]
Identify a ``point'' person to
answer questions about the status of the
development of new, and the updating of
existing, policies or regulations.
D. Simplifying Information
Processes and Requirements:
1. Designating HMO- Allow HMOs to designate an HMO-
specific and Corporate specific and corporate liaison.
Medicare Liaisons. Carbon copy designated Medicare
liaison on all communications.
2. Streamline Application Streamline application process
Process. to be ``less paper bound'' and more real-
time activity.
Designate appropriate
``boilerplate'' sections of the
application.
3. Real-Time, On-Line Strive to make Medicare
Medicare Beneficiary beneficiary eligibility a real-time, on-
Eligibility. line activity.
Allow HMOs to maintain system
logs for documentation.
4. Streamline Marketing Institute a national ``use and
Approval Process. file'' policy.
E. Coordination with
Contractors:
Provide sufficient training to
our contractors and reviewers who
perform functions, such as the ACR
review, PRO review, and on-site quality
monitoring before allowing such agents
to perform these functions.
Improve communication between
HCFA, the PROs, and CHDR; clarify
respective roles of HCFA, PROs, CHDR,
and HMOs.
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In addition, a number of potential ways that we could communicate
information to Medicare risk contract HMOs has been identified. It is
likely that the most effective communication strategies may be
different for Medicare risk HMOs with different characteristics and
that we may want to develop multiple communication strategies to ensure
that information is provided appropriately to all Medicare HMOs. Table
5 describes communication strategies that we have identified during
preliminary discussions with program participants.
Table 5.--Summary of Major Recommendations
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A. Communication Strategy:
1. Written Materials..... Written materials should be
clear and complete; changes made to
updated policies, regulations, and
manuals should be explicit.
Materials should be organized to
ensure that all written materials on a
specific topic are available in one
place and/or are cross-referenced with
other related materials.
One contact point should be
designated for HMOs to identify and
request all written materials that are
available. This could be on the HCFA
Website, with a dedicated e-mail address
or an 800 number specifically for
ordering written materials.
We should move towards providing
timely written responses to outstanding
inquiries and issues currently answered
verbally. Currently, HMOs find the need
to maintain extensive documentation of
verbal communications. The use of e-mail
would facilitate this.
Currently, HMOs believe that
they are not well informed of the status
of our various activities (not all HMOs
are members of the American Association
of Healthcare Plans (AAHP) or have
access to outside counsel or government
affairs programs in Washington, D.C.)
and it is easy to lose track of the
initiatives over time because of
sporadic communications.
We should create and disseminate
a newsletter which could provide timely
and concise information on our
activities, such as initiatives,
demonstrations, and pilot programs, as
well as the status of regulatory
developments, that may offer HMOs
opportunities to participate or may
affect their operations.
--Most HMOs would be willing to pay to
receive a newsletter that provided them
with information and understanding of
our initiatives and regulations.
2. Verbal Communication, HMOs would like one person
by Telephone and In- assigned to serve as their contact
Person. person for the coordination of all
activities and for seeking clarification
to questions.
We should update our voice mail
to indicate absences, and designate an
appropriate back-up person with the
authority to answer questions.
We should set up a telephone
hotline that HMOs could access to
receive clarification and consistent
answers to specific regulatory or
operational issues.
We should develop a fax-on-
demand service to provide up-to-date
information on hot topics, as the Agency
for Health Care Policy and Research and
provider associations have done.
3. E-mail and Electronic Many HMOs would prefer e-mail
Data Transfers. communication to verbal communications.
E-mail would facilitate transmittal of
questions and responses that are
currently being handled by telephone and
would produce written documentation of
the issue discussed and guidance
received.
HMOs would like us to make
beneficiary eligibility a real-time, on-
line activity that would improve the
timeliness and accuracy of our data and
enable Medicare beneficiaries to be
enrolled sooner. They would like to be
able to show a log for documentation
rather than paper copies in a file.
We should move towards accepting
the electronic file transfer of draft
marketing materials. This procedure
would permit us to make changes directly
in the document, and return them to the
HMOs in a timely manner, and produce
documentation of comments and approval.
HMOs support our collection of
ACRs on-line, noting this was a pilot
project in 1996 that will be mandatory
in 1997. However, not all plans received
the relevant documentation or received
it after their ACRs had been submitted.
Some HMOs attempting the electronic
submission were unsuccessful in doing
so, because of the system freezing or
designated passwords not working. HMOs
believe strongly that, before making a
new procedure mandatory, we should first
test the system to ensure it works and
then disseminate the information in a
timely manner prior to implementation.
Implement a mechanism(s) for
systematically tracking various HMO
materials in review. Most useful to be
able to track are:
[[Page 10926]]
Applications and Service Area
Expansions; Review of Marketing
Materials; and ACR filings.
4. HCFA Website.......... HMOs would like to see us expand the
amount of information available through
the HCFA Website, and develop a process
for posting information on a more
routine and timely basis (within 1 to 2
weeks of release). Increased posting of
materials on the HCFA Website would
reduce our burden in copying and mailing
requested materials. Materials that the
HMOs would like made available through
the website are--
OPLs--the complete catalog of
OPLs be made available on the Internet;
at a minimum, HMOs would like a
comprehensive index of available OPLs by
subject area;
General information about HCFA,
including conferences where staff will
be speaking and a directory of staff by
responsibility for specific areas and
issues, with telephone numbers and e-
mail addresses;
Routine HCFA reports; and
relevant statistics and data. Specific
examples of reports and data cited
include--
--Medicare/Medicaid Sanction reports,
which some plans currently receive in
hard copy once a year;
--CHDR and BITS reports, and analysis of
disenrollment patterns;
--OSCAR-3 reports, which contain
information that HMOs find helpful and
an added value in credentialing SNFs for
inclusion in provider network;
--List of participating providers;
--Local fee schedules and DRGs; and
--Messages sent through MCCOY, our
Managed Care Option Information on-line
data base system, because data
processors are not the appropriate staff
to receive these.
--Some HMOs indicated that they would be
willing to pay a fee to access reports
on-line through a password system.
5. CD-ROMs............... CD-ROMs of HCFA manuals should
be updated to be compatible with the
Windows program rather than just DOS. We
should consider selecting a standard
word processing program in which to
publish reports and data. Currently,
HMOs are dealing with unformatted, and
sometimes unusable, ASCII files.
OPLs should also be made
available on a CD-ROM.
B. Conferences and Training:
Given the emergence of new Medicare risk
contractors and the use of consultants,
some HMOs believe we should offer the
following courses and seminars to
current and potential risk contractors:
A basic course on Medicare and
the risk contracting program for
inexperienced organizations that are
considering applying for a contract.
An Application Preparation
seminar explaining the various sections
of the application (such as, enrollment
and disenrollment, grievances and
appeals, coverage issues, and marketing
materials) and addressing frequently
asked questions. This presentation would
allow us to more efficiently deliver
information that is repeated to many of
the HMOs during various points of the
application process.
A course for risk contractors
discussing the operational and
regulatory aspects of risk contracting.
--We should require that potential
applicants attend a seminar series prior
to being able to submit an application.
Forums with plans and advocacy
groups on new regulations or new
interpretations of regulations, or new
policies such as HEDIS/CAHPS,
enrollment and payment, and physician
incentive plan regulations are very
helpful to HMOs.
--HMOs would like us to continue offering
such seminars and, to the extent
possible, expand their use.
--The seminars should be offered in a
timely manner to consider the
operational impacts on HMOs.
Periodic Meetings. The HMOs
would like us to conduct meetings on a
regular basis, such as quarterly, that
bring together risk Medicare contractors
to discuss issues affecting all HMOs and
to conduct question and answer sessions.
These sessions would allow us to be
aware of issues and concerns to HMOs, as
well as HMOs to be aware of our
perspective.
Also, our staff who deal
directly with Medicare risk contractors
would benefit from a structured training
program that would enable them to
understand Medicare risk contracting
rules and regulations and HMO
operations, including monitoring of
compliance.
--Structured training could include
direct observation of plan operations to
witness the sophistication of some
operational aspects.
--We may also want to consider having our
reviewers attend the NCQA ``Building
Blocks'' sessions, as well as having at
least one representative from each
Regional Office attend AAHP's annual
Medicare/Medicaid conference that
highlights industry-wide concerns.
------------------------------------------------------------------------
III. Discussion
Under section 4002 of the Balanced Budget Act of 1997 (BBA) (Pub.
L. 105-33), and with the implementation of the Medicare+Choice program,
all HMOs and CMPs will contract with us under requirements of the
Medicare+Choice program. Our preliminary discussions of information
needs, information process, and communication strategies have produced
a significant number of issues that will be considered in the
development of our Medicare risk contract HMO communication strategy.
Although the preliminary research was conducted before the BBA, the
results are applicable to the Medicare+Choice program. However, since
only a relatively small number of HMOs and other organizations have
participated in
[[Page 10927]]
this preliminary process, we are seeking additional comments and
suggestions on these issues. Respondents should prioritize issues
raised in the preliminary research and identify additional areas of
information needs and communication strategies. In addition, it would
be useful to obtain comments on those issues that would be most likely
to improve the effectiveness and efficiency of the Medicare risk
contract program in order to establish priorities and develop a program
to implement the communication strategy. This notice seeks comments and
suggestions related to these issues, that we may use to develop and
refine communications with Medicare risk contract HMOs.
IV. Regulatory Impact Statement
We have examined the impacts of this notice as required by
Executive Order 12866 and the Regulatory Flexibility Act (Public Law
96-354). Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, when regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects; distributive impacts; and equity). The Regulatory Flexibility
Act (RFA) requires agencies to analyze options for regulatory relief
for small businesses. Most HMOs are small entities, either by nonprofit
status or by having revenues of $5 million or less annually. For
purposes of the RFA, HMOs are considered small entities.
Section 1102(b) of the Social Security Act requires us to prepare a
regulatory impact analysis for any rule that may have a significant
impact on the operations of a substantial number of small rural
hospitals. Such an analysis must conform to the provisions of section
603 of the RFA. For purposes of section 1102(b) of the Act, we define a
small rural hospital as a hospital that is located outside a
metropolitan Statistical Area and has fewer than 50 beds.
Preliminary research on the information needs of Medicare risk
contract HMOs and effective communication strategies has identified a
number of areas in which we could provide additional information to
HMOs and has identified potential strategies for communicating that
information more effectively. The purpose of this notice is to seek
public comments on the information needs of Medicare risk contract HMOs
and communication strategies that could improve the effectiveness and
efficiency of the risk contract program. For these reasons, we are not
preparing an analysis for either the RFA or section 1102(b) of the Act
because we have determined, and we certify, that this notice would not
have a significant impact on a substantial number of small entities or
a significant impact on the operations of a substantial number of small
rural hospitals.
In accordance with the provisions of Executive Order 12866, this
notice was not reviewed by the Office of Management and Budget.
V. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and the time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will respond to the comments in that document.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance Program)
Dated: November 26, 1997.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
[FR Doc. 98-5234 Filed 3-4-98; 8:45 am]
BILLING CODE 4120-01-P