[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

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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