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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

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Information about this document as published in the Federal Register.

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


Final notice.


This final notice announces the decision to renew the Medicare Advantage Deeming Authority of the National Committee for Quality Assurance (NCQA) for Health Start Printed Page 16794Maintenance 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.


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

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Caroline L. Baker, (410) 786-0116.

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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 § 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 § 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 § 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 § 422.157(d).

No comments were received in response to the proposed notice published November 29, 2010. Start Printed Page 16795Therefore, 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)

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Dated: March 9, 2011.

Donald M. Berwick,

Administrator, Centers for Medicare & Medicaid Services.

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[FR Doc. 2011-6222 Filed 3-24-11; 8:45 am]