[Federal Register Volume 71, Number 102 (Friday, May 26, 2006)]
[Notices]
[Pages 30422-30423]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E6-8135]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4117-FN]


Medicare Program; Approval of URAC for Deeming Authority for 
Medicare Advantage Health Maintenance Organizations and 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 URAC for deeming 
authority as a national accreditation organization for health 
maintenance organizations and local preferred provider organizations 
participating in the Medicare Advantage program, for a term of 6 years 
upon publication of this notice in the Federal Register. This notice 
describes the processes and criteria used in evaluating the 
application. We did not receive any public comments during the public 
comment period, which ended on April 28, 2006.

FOR FURTHER INFORMATION CONTACT: Shaheen Halim, Ph.D., (410) 786-0641.

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 uses a 
written protocol that itemizes the Medicare requirements the MA 
organization must meet.
    As an alternative for meeting some Medicare requirements, an MA 
organization may be exempt from our 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). In essence, 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.
    An organization that applies for MA deeming authority is generally 
recognized by the industry as an entity that accredits MCOs that are 
licensed as a health maintenance organization (HMO) or a preferred 
provider organization (PPO). As we specify at

[[Page 30423]]

Sec.  422.157(b)(2) of our regulations, the term for which an AO may be 
approved by us may not exceed 6 years. For continuing approval, the AO 
must re-apply to us.

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 
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 a 
notice identifying receipt of an organization's application identifying 
the national accreditation body making 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 March 24, 2006, we published a proposed notice in the Federal 
Register (71 FR 14922) announcing URAC's October 12, 2005 application 
for deeming authority for MA HMOs and local PPOs in the following six 
areas:
     Quality improvement.
     Antidiscrimination.
     Access to services.
     Confidentiality and accuracy of enrollee records.
     Information on advance directives.
     Provider participation rules.
    In the proposed notice, we described our evaluation criteria. Under 
Sec.  422.158(a), this includes but is not limited to, the following:
     The equivalency of URAC's requirements for HMOs and PPOs 
to our comparable MA organization requirements.
     URAC'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;
    + Types and categories of accreditation offered and MA 
organizations currently accredited within those types and categories.
    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. We also 
must have an opportunity to observe the applicant using the 
accreditation processes under which it intends to deem compliance. 
Those observational site visits allow us to verify that the information 
presented in the application is correct and to make a determination on 
the application.
    In accordance with section 1865(b)(3)(A) of the Act, the proposed 
notice solicited public comment on the ability of URAC's accreditation 
program to meet or exceed the Medicare requirements for which it seeks 
authority to deem. We did not receive any public comments in response 
to the proposed notice.

IV. Evaluation of Application for Deeming Authority

    Following the receipt of URAC's application for deeming authority 
on October 12, 2005, for MA organizations that are licensed as either 
HMOs or PPOs, we began our review and evaluation under Sec.  422.158(a) 
of the regulations. Our review and evaluation included, but was not 
limited to, the information and criteria provided in sections II and 
III of this final notice. Additionally, we observed on-site application 
of URAC's accreditation processes twice at two separate managed care 
organizations. Following these two observational opportunities, we 
determined that URAC's criteria and methods of evaluating MA plans meet 
or exceed ours. We grant approval of URAC's application for deeming 
authority for MA HMOs and local PPOs for a term of 6 years beginning 
upon publication of this final notice.

V. Executive Order 12866 Statement

    In accordance with the provisions of Executive Order 12866, this 
regulation 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-22 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: May 17, 2006.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicare Services.
 [FR Doc. E6-8135 Filed 5-25-06; 8:45 am]
BILLING CODE 4120-01-P