[Federal Register Volume 79, Number 166 (Wednesday, August 27, 2014)]
[Notices]
[Pages 51170-51172]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-20446]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4132-FN]
Medicare and Medicaid Programs; Renewal of Deeming Authority of
the Accreditation Association for National Committee for Quality
Assurance (NCQA)
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final notice.
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SUMMARY: This final notice announces our decision to renew the Medicare
Advantage ``deeming authority'' of the National Committee for Quality
Assurance (NCQA) for a period of 6 years. This new term of approval
would begin October 19, 2014 and end October 18, 2020.
DATES: This final notice is effective October 19, 2014 through October
18, 2020.
FOR FURTHER INFORMATION CONTACT: Jennifer Bates, 410-786-6258 or
Milonda Mitchell, 410-786-1644.
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). The
regulations specifying the Medicare requirements
[[Page 51171]]
that must be met for a Medicare Advantage Organization (MAO) to enter
into a 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 MAO must provide and
the requirements that the organization must meet to offer 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. Under Sec.
422.400, one significant prerequisite for an entity to be an MA
organization is that the organization be licensed by the state as a
risk bearing organization, unless a waiver is authorized for a
provider-sponsored organization pursuant to Sec. 422.370. In addition,
MAOs and MA plans must meet requirements related to access to services,
antidiscrimination, confidentiality and accuracy of beneficiary
records, provider participation, advance directives, and quality
assurance programs.
As a method of assuring compliance with certain Medicare
requirements, an MA organization may choose to become accredited by a
CMS approved accrediting organization (AO). In addition to their CMS-
recognized deemed status accreditation program, approved AOs offer
other accreditation programs that are not recognized by CMS. For
Medicare participation purposes, the MA organization may be ``deemed''
compliant in one or more of six requirements set forth in section
1852(e)(4)(B) of the Act and Sec. 422.156(b). For an AO to be able to
``deem'' an MA plan as compliant with these MA requirements, the AO
must demonstrate that it meets the requirements outlined in Sec.
422.157, including demonstrating that its standards are at least as
stringent as Medicare requirements with respect to the standards in the
deemable area. Therefore, for example, 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 the MA organization's request,
deemed status for CMS requirements in the following six MA areas:
Quality Improvement, Antidiscrimination, Access to Services,
Confidentiality and Accuracy of Enrollee Records, Information on
Advanced Directives, and Provider Participation Rules. (See 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 specified at Sec. 422.157(b)(2)(ii), the
term for which an AO may be approved by CMS may not exceed 6 years. For
continuing approval, the AO must renew its application with CMS.
The National Committee for Quality Assurance (NCQA) was approved as
an accrediting organization for MA deeming of HMOs on October 19, 2010,
and that term will expire on October 18, 2014. On January 30, 2014,
NCQA submitted an application to renew its deeming authority. On that
same date, NCQA submitted materials requested from CMS which included
updates and/or changes to items listed in Sec. 422.158(a) that are
prerequisites for receiving deeming program approval by CMS, and which
were furnished to CMS by NCQA as a part of its renewal applications for
HMOs and PPOs.
II. Deeming Applications Approval Process
Section 1852(e)(4)(c) of the Act provides a statutory timetable to
ensure that our review of deeming applications is 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. In accordance with our policy for providers
and suppliers, within 60 days of receiving a completed application, we
must publish a notice in the Federal Register that identifies the
national accreditation body making the request, describes the request,
and provides no less than a 30-day public comment period. At the end of
the 210-day period, we must publish an approval or denial of the
application.
III. Proposed Notice
In the March 25, 2014, Federal Register (79 FR 16338), we published
a proposed notice announcing NCQA's request for continued CMS approval
of its deeming authority for MA HMOs and PPOs. In the proposed notice,
we detailed our evaluation criteria. Under section 1852(e)(4) of the
Act and our regulations at Sec. 422.158 (Federal review of accrediting
organizations), 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 types of MA plans that it would review as part of its
accreditation process.
A detailed comparison of the AO's accreditation
requirements and standards with the Medicare requirements (for example,
a crosswalk).
Detailed information about the organization's survey
process, including the following--
++ Frequency of surveys and whether surveys are announced or
unannounced.
++ Copies of survey forms, and guidelines and instructions to
surveyors.
++ Descriptions 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; and
-- The procedures used to enforce compliance with accreditation
requirements.
Detailed information about the individuals who perform
surveys for the accreditation organization, including the following--
++ 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; and
++ 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, partial)
and categories (for example, provisional, conditional, temporary) of
accreditation offered by
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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.
The name and address of each person with an ownership or
control interest in the accreditation organization.
CMS's analysis of NCQA's past performance in the deeming
program and the 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).
In accordance with section 1865(a)(3)(A) of the Act, the March 25,
2014 proposed notice (79 FR 16338) also solicited public comments
regarding whether NCQA's requirements met or exceeded the Medicare
conditions of participation as an accrediting organization for MA HMOs
and PPOs. We received no public comments in response to our proposed
notice.
IV. Provisions of the Final Notice
A. Differences Between NCQA's Standards and Requirements for
Accreditation and Medicare's Conditions and Survey Requirements
We compared the standards and survey process contained in NCQA's
application with the Medicare conditions for accreditation. Our review
and evaluation of NCQA's application for continued CMS-approval were
conducted as described in section III of this final notice, and yielded
the following:
To meet the requirements at Sec. 422.158(a)(1), NCQA
provided CMS with documentation listing its types of MA plans that it
would review as part of its accreditation process. In addition, AO
provided clarification and documentation to demonstrate how it
distinguishes its CMS-recognized deemed status accreditation program
from its other accreditation programs that are not recognized by CMS.
AO revised its ``Grounds of Revocation'' policy to meet
the requirements at Sec. 422.158(a)(3)(iii)(C) by revising its
requirements to include non-compliance with ``State, Federal, or other
duly authorized regulatory or judicial action restricts or limits the
organization's operations.''
To comply with the requirements at Sec. 422.158(a)(6), AO
revised its processes for responding to and investigating complaints
against accredited organizations by requiring the reporting of any
serious problems identified with an MA plan to the designated CMS MA
deeming representative.
B. Term of Approval
Based on the review and observations described in section III of
this final notice, we have determined that NCQA's accreditation program
requirements continue to meet or exceed our requirements. Therefore, we
renew NCQA as a national accreditation organization with deeming
authority for MA HMOs and PPOs, effective October 19, 2014 through
October 18, 2020.
V. Collection of Information Requirements
This document does not impose any new or revised information
collection or 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.
Dated: August 15, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2014-20446 Filed 8-26-14; 8:45 am]
BILLING CODE 4120-01-P