[Federal Register Volume 84, Number 98 (Tuesday, May 21, 2019)]
[Notices]
[Pages 23054-23055]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-10586]
[[Page 23054]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4188-FN]
Medicare Program; Approved Renewal of Deeming Authority of the
Utilization Review Accreditation Commission 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 notice announces our decision to renew the Medicare
Advantage ``deeming authority'' of the Utilization Review Accreditation
Commission (URAC) for health maintenance organizations and preferred
provider organizations for a term of 6 years.
DATES: The renewal announced in this notice is effective on May 31,
2019 through June 2, 2025.
FOR FURTHER INFORMATION CONTACT: Greg McDonald, (410) 786-8941; or Nick
Proy, (410) 786-8407.
SUPPLEMENTARY INFORMATION:
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 its 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 with respect to 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 and
PPOs 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 an 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. URAC submitted all the necessary materials
to enable us to make a determination concerning its request for
approval as an accreditation organization, and the renewal application
was determined to be complete on November 8, 2018.
II. Provisions of the Proposed Notice
In the December 26, 2018 Federal Register (83 FR 66271), we
published a proposed notice announcing URAC's request to renew its
Medicare Advantage deeming authority for HMOs and PPOs. In the December
26, 2018 proposed notice, we detailed our evaluation criteria. Under
section 1852(e)(4) of the Act and Sec. 422.158 (Federal review of
accrediting organizations), we conducted a review of URAC'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) 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 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
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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 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 also considers 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).
In accordance with section 1865(a)(3)(A) of the Act, the December
26, 2018 proposed notice (83 FR 66271) also solicited public comments
regarding whether URAC'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 the December
26, 2018 proposed notice (83 FR 66271).
III. Provisions of the Final Notice
A. Differences Between URAC's Standards and Requirements for
Accreditation and Medicare's Conditions and Survey Requirements
We compared the standards and survey process contained in URAC's
application with the Medicare conditions for accreditation. Our review
and evaluation of URAC's application for continued CMS approval were
conducted as described in section II. of this final notice, and yielded
the following:
URAC amended its crosswalk to ensure current URAC
standards are clearly cross-walked to our regulations, including the
following regulatory requirements for Quality Improvement;
Antidiscrimination, Confidentiality and Accuracy of Enrollee Records,
Information on Advanced Directives, and Provider Participation Rules:
Sec. Sec. 422.101(f); 422.205(b); 422.110(a) through (b); 422.118(a);
422.128(b); 422.152(a) and (b), (e) through (g); 422.202(a) through
(d); 422.206(a) through (b); 422.208(c), (e) through (g); 422.210(b);
422.212(a) through (d); and 422.216(f) through (h).
URAC submitted additional information and/or documentation
regarding its survey process that was intended to address: Sec.
422.158(a)(2), (a)(3)(ii), (a)(3)(iii)(A) through (C), (a)(4)(ii) and
(iii), (a)(6) through (10), and (b)(2).
B. Term of Approval
Based on the review and observations described in section II. of
this final notice, we have determined that URAC's accreditation program
requirements meet or exceed our requirements. Therefore, we approve
URAC as a national accreditation organization with deeming authority
for MA HMOs and PPOs, effective May 21, 2019.
V. Collection of Information Requirements
This notice announces the new term of approval for the URAC. It
does not impose any 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.).
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.
Dated: May 2, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2019-10586 Filed 5-20-19; 8:45 am]
BILLING CODE 4120-01-P