[Federal Register Volume 76, Number 58 (Friday, March 25, 2011)]
[Notices]
[Pages 16793-16795]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-6222]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[CMS-4154-FN]


Medicare and Medicaid Programs; Renewal of Deeming Authority of 
the National Committee for Quality Assurance for Medicare Advantage 
Health Maintenance Organizations and Local Preferred Provider 
Organizations

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

ACTION: Final notice.

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SUMMARY: This final notice announces the decision to renew the Medicare 
Advantage Deeming Authority of the National Committee for Quality 
Assurance (NCQA) for Health

[[Page 16794]]

Maintenance Organizations and Preferred Provider Organizations for a 
term of 4 years. The new term of approval began October 19, 2010, and 
ends October 18, 2014.

DATES: Effective Date: This notice is effective on April 25, 2011.

FOR FURTHER INFORMATION CONTACT: Caroline L. Baker, (410) 786-0116.

SUPPLEMENTARY INFORMATION:

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services through a Medicare Advantage (MA) organization that 
contracts with the Centers for Medicare & Medicaid Services (CMS) 
provided certain requirements are met under 42 CFR part 422. Part C of 
Title XVIII of the Social Security Act (the Act), specifies the 
services that an MA organization 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 of the Act pertaining to the provision of services by Medicare 
certified providers and suppliers.
    To assure compliance with certain Medicare requirements, an MA 
organization may chose to become accredited by a CMS approved 
accrediting organization (AO). By doing so, the MA organization may be 
``deemed'' compliant in one or more of 6 requirements set forth in 
section 1852(e)(4)(B) of the Act. In order for an AO to be able to 
``deem'' an MA plan as compliant with these MA requirements, the AO 
must prove to CMS that its standards are at least as stringent as the 
Medicare requirements. MA organizations that are licensed as health 
maintenance organizations (HMOs) or preferred provider organizations 
(PPOs) and are accredited by an approved accrediting organization may 
receive, at their request, deemed status for CMS requirements in the 
following 6 MA survey areas: (1) Quality Improvement; (2) 
Antidiscrimination; (3) Access to Services; (4) Confidentiality and 
Accuracy of Enrollee Records; (5) Information on Advanced Directives; 
and (6) Provider Participation Rules. (See 42 CFR 422.156(b).) We note 
that at this time, deeming does not include the Part D areas of review 
listed in Sec.  422.156(b).
    Organizations that apply for MA deeming authority are generally 
recognized by the health care industry as entities that accredit HMOs 
and PPOs. As we specified in Sec.  422.157(b)(2), the term for which an 
AO may be approved by CMS may not exceed 6 years. For continuing 
approval, the AO must renew their application with CMS.

II. Approval of Deeming Organizations

    Section 1852(e)(4)(C) of the Act provides a statutory timetable to 
ensure that our review of deeming applications in conducted in a timely 
manner. The Act provides us with 210 calendar days after the date of 
receipt of an application to complete our survey activities and 
application review process. At the end of the 210 day period, we must 
publish an approval or denial of the application in the Federal 
Register.

III. Provisions of the Proposed Notice and Response to Comments

    On November 29, 2010, we published a proposed notice (75 FR 73087) 
in the Federal Register announcing re-approval of Medicare Advantage 
Deeming Authority of the National Committee for Quality Assurance 
(NCQA). In the proposed notice, we detailed our evaluation criteria. As 
set forth in section 1852(e)(4) of the Act and our regulations at Sec.  
422.158, the review and evaluation of NCQA's accreditation program 
(including its standards and monitoring protocol) were compared to the 
requirements set forth in part 422 for the MA program.
    The review of NCQA's application for approval of MA deeming 
authority included the following components:
     The types of MA plans that it would review as part of its 
accreditation process.
     A detailed comparison of the organization's accreditation 
requirements and standards with the Medicare requirements (for example, 
a crosswalk).
     Detailed information about the organization's survey 
process, including--
    ++ Frequency of surveys and whether surveys are announced or 
unannounced.
    ++ Copies of survey forms, and guidelines and instructions to 
surveyors.
    ++ Description of the survey review process and the accreditation 
status decision making process.
    ++ The procedures used to notify accredited MA organizations of 
deficiencies and to monitor the correction of those deficiencies.
    ++ The procedures used to enforce compliance with accreditation 
requirements.
     Detailed information about the individuals who perform 
surveys for the accreditation organization, including--
    ++ The size and composition of accreditation survey teams for each 
type of plan reviewed as part of the accreditation process.
    ++ The education and experience requirements surveyors must meet.
    ++ The content and frequency of the in-service training provided to 
survey personnel.
    ++ The evaluation systems used to monitor the performance of 
individual surveyors and survey teams.
     The organization's policies and practice with respect to 
the participation, in surveys or in the accreditation decision process 
by an individual who is professionally or financially affiliated with 
the entity being surveyed.
     A description of the organization's data management and 
analysis system with respect to its surveys and accreditation 
decisions, including the kinds of reports, tables, and other displays 
generated by that system.
     A description of the organization's procedures for 
responding to and investigating complaints against accredited 
organizations, including policies and procedures regarding coordination 
of these activities with appropriate licensing bodies and ombudsmen 
programs.
     A description of the organization's policies and 
procedures with respect to the withholding or removal of accreditation 
for failure to meet the accreditation organization's standards or 
requirements, and other actions the organization takes in response to 
noncompliance with its standards and requirements.
     A description of all types (for example, full and partial) 
and categories (for example, provisional, conditional, and temporary) 
of accreditation offered by the organization, the duration of each type 
and category of accreditation, and a statement identifying the types 
and categories that would serve as a basis for accreditation if CMS 
approves the accreditation organization.
     A list of all currently accredited MA organizations and 
the type, category, and expiration date of the accreditation held by 
each of them.
     A list of all full and partial accreditation surveys 
scheduled to be performed by the accreditation organization as 
requested by CMS.
     The name and address of each person with an ownership or 
control interest in the accreditation organization.
     The NCQA's past performance in the deeming program and 
results of recent deeming validation reviews, or look-behind audits 
conducted as part of continuing Federal oversight of the deeming 
program under Sec.  422.157(d).
    No comments were received in response to the proposed notice 
published November 29, 2010.

[[Page 16795]]

Therefore, based on the review and observations described in section 
III of this final notice, we have determined that NCQA's requirements 
for HMOs and local PPOs continue to meet or exceed our requirements. We 
renew the MA deeming authority of the NCQA for HMOS and PPOs for a term 
of 4 years. The new term of approval began October 19, 2010, and ends 
October 18, 2014.

IV. Results of the Review Process

    Using the information listed in section III of this final notice, 
we determined that NCQA's current accreditation program for HMO and PPO 
MA plans continues to be at least as stringent as the MA requirements 
contained in the 6 categories specified in section 1852(e)(4)(C) of the 
Act and our methods of evaluation for those areas.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35).

VI. Regulatory Impact Statement

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

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

    Dated: March 9, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2011-6222 Filed 3-24-11; 8:45 am]
BILLING CODE 4120-01-P