[Federal Register Volume 83, Number 246 (Wednesday, December 26, 2018)]
[Notices]
[Pages 66271-66273]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-27802]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4188-PN]
Medicare Program; Request for Renewal of Deeming Authority of the
Utilization Review Accreditation Commission (URAC) for Health
Maintenance Organizations and Preferred Provider Organizations
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed notice.
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SUMMARY: This proposed notice announces that CMS is considering
granting approval of the Utilization Review Accreditation Commission's
(URAC) renewal application for Medicare Advantage ``deeming authority''
of Health Maintenance Organizations and Preferred Provider
Organizations. This new 6-year term of approval would begin on the date
of publication of the final notice. This notice also announces a 30-day
period for the public to submit comments on CMS' renewal of the
application.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. January 25, 2019.
ADDRESSES: In commenting, refer to file code CMS-4188-PN. Because of
staff and resource limitations, we cannot accept comments by facsimile
(FAX) transmission.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-4188-PN, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-4188-PN,
[[Page 66272]]
Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
FOR FURTHER INFORMATION CONTACT: Greg McDonald, (410) 786-8941; or Nick
Proy, (410) 786-8407.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to
view public comments.
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services through a Medicare Advantage (MA) organization that
contracts with CMS. The regulations specifying the Medicare
requirements 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 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 entity to be an MA organization, the organization must be licensed
by the state as a risk bearing organization, as set forth in 42 CFR
part 422.
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). By virtue of its
accreditation by a CMS-approved AO, the MA organization may be
``deemed'' compliant in one or more requirements set forth in section
1852(e)(4)(B) of the Act. For CMS to recognize an AO's accreditation
program as establishing an MA plan's compliance with our requirements,
the AO must prove to CMS that their standards are at least as stringent
as Medicare requirements for MA organizations. 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 for the deemable areas. At this time,
recognition of accreditation does not include the Part D areas of
review set out at 42 CFR 423.165(b). AOs that apply for MA deeming
authority are generally recognized by the health care industry as
entities that accredit HMOs and PPOs. As we specify 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 apply to CMS
to renew their ``deeming authority'' for a subsequent approval period.
The Utilization Review Accreditation Commission (URAC) was approved
as a CMS approved accreditation organization for MA deeming of HMOs on
May 26, 2012, and that term lapsed on May 25, 2018 prior to our
decision on its renewal application. On October 13, 2017 URAC submitted
its initial application to renew its deeming authority. On that same
date, URAC submitted materials requested by CMS that included
information intended to address the requirements set out at Sec.
422.158(a) through (b) that are prerequisites for receiving approval of
its accreditation program from CMS. CMS subsequently requested that
additional materials, including revisions, be submitted by URAC to
satisfy these requirements.
II. Provisions of the Proposed Notice
The purpose of this notice is to notify the public of URAC's
request to renew its Medicare Advantage deeming authority for HMOs and
PPOs. URAC submitted all the necessary materials (including its
standards and monitoring protocol) to enable us to make a determination
concerning its request for approval as an accreditation organization
for CMS. This renewal application was determined to be complete on
November 8, 2018. Under section 1852(e)(4) of the Act and Sec. 422.158
(federal review of accrediting organizations), our review and
evaluation of URAC will be conducted as discussed below.
A. Components of the Review Process
The review of URAC's renewal application for approval of MA deeming
authority includes, but is not limited to, the following components:
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) in the following 5 areas: Quality Improvement, Anti-
Discrimination, Confidentiality and Accuracy of Enrollee Records,
Information on Advance Directives, and Provider Participation Rules.
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.
++ 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 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 for 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 for the 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 for 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
[[Page 66273]]
example, provisional, conditional, 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.
The name and address of each person with an ownership or
control interest in the accreditation organization.
CMS will also consider URAC'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).
B. Notice Upon Completion of Evaluation
Upon completion of our evaluation, including evaluation of comments
received as a result of this notice, we will publish a notice in the
Federal Register announcing the result of our evaluation. 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. At the end of the 210-day period, we must publish an approval
or denial of the application in the Federal Register.
III. Collection of Information Requirements
This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).
IV. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
Dated: December 14, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2018-27802 Filed 12-21-18; 8:45 am]
BILLING CODE 4120-01-P