[Federal Register Volume 69, Number 250 (Thursday, December 30, 2004)]
[Notices]
[Pages 78444-78445]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-28154]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4077-FN]
RIN 0928-ZA59


Medicare Program; Approval of the National Committee for Quality 
Assurance Deeming Authority for Medicare Advantage Local Preferred 
Provider Organizations

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

ACTION: Final notice.

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SUMMARY: This final notice announces the approval of the National 
Committee for Quality Assurance for deeming authority as a national 
accreditation program for local preferred provider organizations that 
wish to participate in the Medicare Advantage program.

FOR FURTHER INFORMATION CONTACT: Gwyneveyre Pasquale, (410) 786-7701.

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services through a managed care organization (MCO) that has a 
Medicare Advantage (MA) (formerly, Medicare+Choice) 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 enter into an MA 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 
MA 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 MA contract, the 
organization must be licensed by the State as a risk bearing 
organization as set forth in part 422 of our regulations. Additionally, 
the organization must file an application demonstrating that it meets 
other Medicare requirements in part 422 of our regulations. Following 
approval of the contract, we engage in routine monitoring and oversight 
audits of the MA organization to ensure continuing compliance. The 
monitoring and oversight audit process is comprehensive and 
incorporates ongoing analysis of various performance data in addition 
to biennial audits by CMS staff who use a written protocol that 
itemizes the Medicare requirements the MA organization must meet.
    As an alternative for some Medicare requirements, an MA 
organization may be exempt from CMS monitoring of certain requirements 
in subsets listed in section 1852(e)(4)(B) of the Act as a result of an 
MA organization's accreditation by a CMS-approved accrediting 
organization (AO); that is, the Secretary deems that the Medicare 
requirements are met based on a determination that the AO's standards 
are at least as stringent as Medicare requirements. As we specify at 
Sec.  422.157(b)(2) of our regulations, the term for which an AO may be 
approved by CMS may not exceed 6 years. For continuing approval, the AO 
must re-apply to CMS.
    The applicant organization is generally recognized as an entity 
that accredits MCOs that are licensed as a health maintenance 
organization (HMO) or a preferred provider organization (PPO).

II. Deeming Application Approval Process

    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 1865(b)(2) 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.
    Section 1865(b)(3)(A) of the Act further requires that we publish, 
within 60 days of receipt of an organization's complete application, a 
notice identifying the national accreditation body making the request, 
describing the nature of the request, and providing at least a 30-day 
public comment period. We must publish a finding of approval or denial 
of the application within 210 days from the receipt of the completed 
application.

III. Provisions of the Proposed Notice

    On September 24, 2004, we published a proposed notice in the 
Federal Register (69 FR 57310) announcing the National Committee for 
Quality Assurance's (NCQA's) request for recognition as a national 
accreditation program for PPOs that wish to participate in the MA 
program. This notice informed the public of our consideration of NCQA's 
application for approval as a deeming authority for MA organizations 
that are licensed as a PPO for the following six categories:
     Quality improvement.
     Access to services.
     Antidiscrimination.
     Information on advance directives.
     Provider participation rules.
     Confidentiality and accuracy of enrollees' records.
    In the notice, we described our evaluation criteria. Under Sec.  
422.158(a), we conducted a review of NCQA's application in accordance 
with the criteria specified by our regulations, which include, but are 
not limited to, the following:
     The equivalency of NCQA's requirements for PPOs to CMS' 
comparable MA organization requirements.
     NCQA's survey process, to determine the following:
    + The frequency of surveys.
    + 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;
    + 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 
complaints against accredited organizations; and
    + Types and categories of accreditation offered and MA 
organizations currently accredited within those types and categories.

[[Page 78445]]

    In accordance with Sec.  422.158(b) of our regulations, 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) of our regulations.
    In accordance with section 1865(b)(3)(A) of the Act, the proposed 
notice also solicited public comment on the ability of the NCQA's 
accreditation program to meet or exceed the Medicare requirements for 
which it seeks authority to deem. We did not receive any public comment 
in response to the proposed notice.

IV. Provisions of the Final Notice

    On August 4, 2004, NCQA submitted all the necessary information to 
permit us to make a determination concerning its request for approval 
as a deeming authority for MA organizations that are licensed as a PPO.
    We compared the standards contained in NCQA's PPO crosswalk and its 
survey process with the Medicare regulations and the PPO survey 
monitoring guide. Our review and evaluation of NCQA's deeming 
application determined that the NCQA standards meet or exceed those 
established by the Medicare program. Therefore, we recognize NCQA as a 
national accreditation organization for local preferred provider 
organizations that wish to participate in the Medicare Advantage 
program, effective October 20, 2004 through October 20, 2010.

V. Collection of Information Requirements

    This final notice does not impose any information collection and 
record keeping requirements subject to the Paperwork Reduction Act 
(PRA). Consequently, it does not need to be reviewed by the Office of 
Management and Budget (OMB) under the authority of the PRA.

VI. Executive Order 12866 Statement

    In accordance with the provisions of Executive Order 12866, this 
notice was not reviewed by the Office of Management and Budget.

    Authority: Sections 1852 and 1865 of the Social Security Act (42 
U.S.C. 1395w-23 and 1395bb) (Catalog of Federal Domestic Assistance 
Program No. 93.773, Medicare--Hospital Insurance; and Program No. 
93.774, Medicare--Supplementary Medical Insurance Program)

    Dated: November 24, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 04-28154 Filed 12-29-04; 8:45 am]
BILLING CODE 4120-01-P