[Federal Register Volume 66, Number 181 (Tuesday, September 18, 2001)]
[Notices]
[Pages 48147-48149]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-23194]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4026-PN]
RIN 0938-ZA21


Medicare Program; Medicare+Choice Organizations--Application by 
the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO) for Approval of Deeming Authority for Medicare+Choice 
Organizations That Are Licensed as Health Maintenance Organizations 
(HMOs) or Preferred Provider Organizations (PPOs)

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed notice.

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SUMMARY: This proposed notice announces the receipt of an application 
from the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO) for recognition as a national accreditation program for health 
maintenance organizations (HMOs) and preferred provider organizations 
(PPOs) that wish to participate in the Medicare+Choice program. 
Regulations set forth at 42 CFR 422.157(b)(1) specify that a Federal 
Register notice will announce our receipt of the accreditation 
organization's application for approval, describe the criteria we will 
use in evaluating the application, and provide at least a 30-day public 
comment period.

DATES: We will consider comments if we receive them at the appropriate

[[Page 48148]]

address, as provided below, no later than 5 p.m. on October 18, 2001.

ADDRESSES: In commenting, please refer to file code CMS-4026-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission. Mail written comments (one original and 
three copies) to the following address ONLY: Centers for Medicare & 
Medicaid Services, Department of Health and Human Services, Attention: 
CMS-4026-PN, P.O. Box 8013, Baltimore, MD 21244-8013.
    Please allow sufficient time for mailed comments to be timely 
received in the event of delivery delays.
    If you prefer, you may deliver (by hand or courier) your written 
comments (one original and three copies) to one of the following 
addresses:

Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201, or
Room C5-16-03, 7500 Security Boulevard, Baltimore, MD 21244-1850.

    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and could be considered late.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Patricia Kurtz, (410) 786-4670.

SUPPLEMENTARY INFORMATION:

Inspection of Public Comments

    Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, at the headquarters of the Centers for 
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, 
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 
p.m. To schedule an appointment to view public comments, phone (410) 
786-7197.

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services either through Medicare's traditional fee-for-service 
program, or through a managed care organization (MCO) that has a 
Medicare+Choice (M+C) contract with the Centers for Medicare & Medicaid 
Services (CMS). The regulations specifying the Medicare requirements 
that must be met in order for an MCO to qualify for and enter into an 
M+C contract with CMS are located at 42 CFR part 422. These regulations 
implement Part C of Title XVIII of the Social Security Act (the Act), 
which specifies the services that an MCO must provide and the 
requirements that the organization must meet to be an M+C contractor. 
Other relevant sections of the Act are Parts A and B of Title XVIII and 
Part A of Title XI pertaining to the provision of services by Medicare 
certified providers and suppliers.
    Generally, for an organization to enter into an M+C contract, the 
organization must be licensed by the State as a risk bearing 
organization as set forth in part 422. Additionally, the organization 
must file an application demonstrating that other Medicare requirements 
in part 422 are met. Following approval of the contract, CMS engages in 
routine monitoring of the M+C organization to ensure continuing 
compliance. The monitoring process is comprehensive and uses a written 
protocol that itemizes the Medicare requirements the M+C organization 
must meet.
    However, an M+C organization may be exempt from CMS monitoring of 
certain requirements in subsets listed in section 1852(e)(4)(C) of the 
Act as a result of an M+C organization's accreditation by a CMS-
approved accrediting organization (AO). In essence, the Secretary 
``deems'' those Medicare requirements to have been met by the M+C 
organization, based on his determination that the AO's standards are at 
least as stringent as Medicare requirements. The term for which an AO 
may be approved by CMS may not exceed 6 years, as stated in 
Sec. 422.157(b)(2)(ii). For continuing approval, the AO will have to 
re-apply to CMS.
    The applicant organization is generally recognized as an entity 
that accredits MCOs that are licensed as an HMO or a Preferred Provider 
Organization. At this time the JCAHO is applying for the M+C deeming 
approval for HMOs and PPOs.

II. Approval of Deeming Organizations

    Section 1852(e)(4)(C) of the Act requires that within 210 days of 
receipt of an application, the Secretary shall determine whether the 
applicant meets criteria specified in section 1852(e)(4) of the Act. 
Under these criteria, the Secretary will consider for a national 
accreditation body, its requirements for accreditation, its survey 
procedures, its ability to provide adequate resources for conducting 
required surveys and supplying information for use in enforcement 
activities, its monitoring procedures for provider entities found out 
of compliance with the conditions or requirements, and its ability to 
provide the Secretary with necessary data for validation.
    The purpose of this proposed notice is to inform the public of our 
consideration of JCAHO's application for approval of deeming authority 
of M+C organizations that are licensed as HMOs or PPOs for the 
following six categories:
     Quality assurance.
     Access to services.
     Antidiscrimination.
     Information on advance directives.
     Provider participation rules.
     Confidentiality and accuracy of enrollees' records.
    This notice also solicits public comment on the ability of the 
applicant's accreditation program to meet or exceed the Medicare 
requirements for which it seeks authority to deem.

III. Evaluation of Deeming Request

    On August 1, 2001, JCAHO submitted all the necessary information to 
permit us to make a determination concerning its request for approval 
as a deeming authority for M+C organizations that are licensed as an 
HMO or a PPO. Under Sec. 422.158(a), our review and evaluation of a 
national accreditation organization will consider, but not necessarily 
be limited to, the following information and criteria:
     The equivalency of JCAHO's requirements for HMOs and PPOs 
to CMS's comparable M+C organization requirements.
     JCAHO's survey process, to determine the following:

 --The frequency of surveys and whether the surveys are announced or 
unannounced.
 --The types of forms, guidelines and instructions used by surveyors.
 --Descriptions of the accreditation decision making process, 
deficiency notification and monitoring process, and compliance 
enforcement process.

     Detailed information about individuals who perform 
accreditation surveys including--

 --Size and composition of the survey team for each type of plan under 
review;
 --Education and experience requirements for the surveyors;
 --In-service training required for surveyor personnel;
 --Surveyor performance evaluation systems; and
 --Conflict of interest policies relating to individuals in the survey 
and accreditation decision process.

     Descriptions of the organization's--

 --Data management and analysis system;
 --Policies and procedures for investigating and responding to

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complaints against accredited organizations;
 --Policies and procedures when a determination is made that an M+C 
organization is not in compliance;
 --Types and categories of accreditation offered and M+C organizations 
currently accredited within those types and categories.

    In accordance with Sec. 422.158(b), the applicant must provide 
documentation relating to--

 --Its ability to provide data in a CMS-compatible format;
 --The adequacy of personnel and other resources necessary to perform 
the required surveys and other activities; and
 --Assurances that it will comply with ongoing responsibility 
requirements specified in Sec. 422.157(c).

    Additionally, the accrediting organization must provide CMS the 
opportunity to observe its accreditation process for managed care 
organizations and must provide other information required by CMS to 
prepare for an onsite visit to the AO's offices to verify 
representations made in the application and to make a determination on 
the application.

IV. Response to Comments and Notice Upon Completion of Evaluation

    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 time specified in the DATES 
section of this preamble, and, if we proceed with a subsequent 
document, we will respond to the major comments in the preamble to that 
document.
    Upon completion of our evaluation, including evaluation of comments 
received as a result of this notice, we will publish a notice in the 
Federal Register announcing the result of our evaluation.
    In accordance with the provisions of E.O. 12866, this proposed 
notice was not reviewed by the Office of Management and Budget.

Section 1853(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w-
23(a)(1)(B))

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare-Hospital Insurance; and Program No. 93.774, Medicare-
Supplementary Medical Insurance Program)

    Dated: August 31, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 01-23194 Filed 9-17-01; 8:45 am]
BILLING CODE 4120-01-P