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Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health Care To Be a Recognized Accrediting Entity for the Accreditation of Qualified Health Plans

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




This notice announces the receipt of an application from the Accreditation Association for Ambulatory Health Care (AAAHC) to be a recognized accrediting entity for the purposes of fulfilling the accreditation requirement as part of qualified health plan (QHP) certification. Regulations require HHS to publish a notice identifying the accrediting entity, summarizing its analysis of whether the accrediting entity meets certain criteria, and providing no less than a 30-day public comment period.


To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on October 15, 2013.


In commenting, please refer to file code CMS-9953-PN. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to 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-9953-PN, P.O. Box 8010, Baltimore, MD 21244-8010.

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-9953-PN, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

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Rebecca Zimmermann, at (301) 492-4396.

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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 Web site as soon as possible after they have been received: Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

I. Background

Regulations at 45 CFR 156.275 require qualified health plan (QHP) issuers to be accredited on the basis of local performance of its QHPs by an accrediting entity recognized by the Department of Health and Human Services (HHS). In a final rule published on July 20, 2012,[1] we established the first phase of an intended two-phase approach to recognize accrediting entities and proposed both the National Committee for Quality Assurance (NCQA) and URAC as recognized accrediting entities. On November 23, 2012, we notified the public that NCQA and URAC had both met the requirements in the final rule to be recognized as an accrediting entity (77 FR 42662 through 42668) and were recognized by the Secretary [2] as accrediting entities for the purposes of QHP certification.

On February 25, 2013, we published a subsequent final rule title, “Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (78 FR 1283),” [3] which amended § 156.275(c) to establish an application and review process to allow additional Start Printed Page 56712accrediting entities to seek recognition. The application submitted by an accrediting entity must include documentation described in § 156.275(c)(4) and demonstrate, in a concise and organized fashion how the accrediting entity meets the requirements of § 156.275 (c)(2) and (3). Specifically, to be recognized, an accrediting entity must provide current accreditation standards and requirements, processes and measure specifications for performance measures to demonstrate via a crosswalk that it meets the conditions described in § 156.275 (c)(2) and (c)(3). Further, once recognized, § 156.275(c)(4)(ii) requires accrediting entities to provide the Secretary with any proposed changes or updates to the accreditation standards and requirements, processes, and measure specifications for performance measures with 60 days' notice prior to public notification. Lastly, § 156.275(c)(5) requires recognized accrediting entities, when authorized by an accredited QHP issuer, to provide specific QHP issuer accreditation survey data elements to the Exchange.

II. Provisions of the Notice

The purpose of this notice is to notify the public of the Accreditation Association for Ambulatory Health Care's (AAAHC) request for recognition by the Secretary as an accrediting entity for the purposes of QHP certification. As part of the application, AAAHC submitted all the required documentation materials described in § 156.275(c)(4). Below we present, our analysis of whether AAAHC meets the criteria described in paragraphs § 156.275 (c)(2) and (3).

1. Summary of CMS's Analysis

We are providing the public with an analysis of AAAHC's completed application, including a review of the current accreditation standards and requirements, processes and measure specifications for performance measures, submitted by AAAHC. Currently, AAAHC is an accrediting body that has a CMS-approved accreditation program to conduct surveys for ambulatory surgery centers that wish to participate in the Medicare program with deemed status. The AAAHC has also obtained approval from CMS as a deeming entity allowing it to survey Medicare Advantage plans.[4] The current scope of accreditation as described in AAAHC's 2013 Accreditation Handbook for Health Plans demonstrates that AAAHC will be providing accreditation of QHPs within the statutorily required categories,[5] established in § 156.275(c), including reporting on a set of clinical quality measures and patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey; consumer access; utilization management; quality assurance; provider credentialing; complaints and appeals; network adequacy and access; and patient information programs.

In addition, CMS evaluated AAAHC's standards relating to network adequacy and consider them to be consistent with the general requirements for network adequacy for QHP issuers (45 CFR 156.230(a)(2) and (3)). To determine health plans' compliance with network adequacy standards, the AAAHC accreditation survey includes review of areas such as member choice of providers, member satisfaction with relation to provider access, availability of services, provider network credentialing and customer complaints, appeals, and satisfaction information.

Upon review of the clinical quality measures included in AAAHC's accreditation standards, we have assessed that the measures cover a range of conditions and domains, include adult and child-specific measures, align with the priorities in the National Strategy for Quality Improvement in Health Care, are developed or adopted by the National Quality Forum (NQF) or are in common use for health plan quality measurement, and meet health plan industry standards and are evidence-based, as required in § 156.275(c)(2)(ii). The following list displays the clinical quality measures that will be used for QHP accreditation by AAAHC, spanning preventive care, behavioral health and substance abuse disorders, chronic care, and acute care:

MeasureNQF reference No.Measure develop/steward
Mandatory Measures
Proportion of Days Covered (Drug Therapy Adherence)0541Pharmacy Quality Alliance (PQA).
Provider Network Adequacy—Number of Specialists Accepting New Patients At End of Reporting Period by Specialist Typen/aCenters for Medicare and Medicaid Services (CMS).
Dyslipidemia New Medication 12-Week Testingn/aResolution Health, Inc.
Drug-Drug Interactionsn/aPQA.
Diabetes Short Term Complications Event Rate0272Adapted by URAC from Agency for Healthcare Quality and Research (AHRQ) measure.
Diabetes Long Term Complications Admission Rate0274Adapted by URAC from AHRQ measure.
Adult Asthma Event Rate0283Adapted by URAC from AHRQ measure.
Pediatric Asthma Event Raten/aAdapted by URAC from AHRQ measure.
Mandatory/Equivalent Measures
Atherosclerotic Disease—Lipid Panel Monitoring0616Active Health Management.
Diabetes All-Or-None Process Measure (HbA1c, LDL-C, Nephropathy)n/aWisconsin Collaborative for Healthcare Quality.
Provider Network Adequacy—Primary Caren/aCMS.
Medication Therapy For Patients With Asthma: Suboptimal Asthma Control (SAC), and Absence of Controller Therapy (ACT)0548PQA.
Call Center Performancen/aURAC.
Percentage of Live Births Weighing Less than 2,500 Grams0278AHRQ.
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Annual Percentage of Asthma Patients 2 through 20 Years Old with One or More Asthma-related Emergency Room Visits1381Alabama Medicaid.
Percentage of Female Patients Who Had a Mammogram Performed During the Two-Year Measurement Periodn/aAmerican Medical Association/Physician Consortium Performance Improvement (AMA/PCPI).
High Risk for Pneumococcal Disease—Pneumococcal Vaccination0617ActiveHealth Management.
Preventive Services: Percentage of Enrolled Members Ages Less than or Equal to 18 years Who have had Preventive Services, Recommended Risk Factor Reductions and Behavioral Health Change Interventions, Appropriate Screenings and Immunizationsn/aAmerican Academy of Pediatrics/URAC.
Colorectal Cancer Screeningn/aVeterans Health Administration (VHA).
Tobacco Use: Screening and Cessation0028AMA/PCPI/URAC.
Prevention and Management of Obesity in Mature Adolescents and Adultsn/aInstitute for Clinical Systems Improvement(ICSI)/URAC.
30 Day Post-Hospital AMI Discharge Care Transition Composite Measure0698Centers for Medicare and Medicaid Services (CMS)/URAC.
Congestive Heart Failure (CHF) Rate0358AHRQ/URAC.
Atrial Fibrillation—Warfarin Therapy0264ActiveHealth Management.
MRI Lumbar Spine for Low Back Pain0514CMS.
All Cause Readmission Index0505United Health Group/URAC.
Central Venous Catheter-related Bloodstream Infections (area-level): Rate per 100,000 Populationn/aAHRQ.
Depression Readmissionn/aMinnesota Community Measurement/URAC.
Follow-up After Hospitalization for a Mental Illnessn/aFlorida Agency for Health Care Administration.
CAHPS® Adult Health Plan Survey 5.00006AHRQ.
CAHPS® Child Survey v4.0 Medicaid and Commercial Core Surveyn/aAHRQ.
CAHPS® Survey for Children With Chronic Conditions0009AHRQ.
Exploratory Measures
Case Management: Consumer Contactn/aURAC.
Complaint Response Timelinessn/aURAC.
Outpatient Newborn Visit Within One Month of Birthn/aCentene.
Diabetes: All or None Process Measure: Optimal Results for HbA1c, LDL-C, and Blood Pressuren/aWisconsin Collaborative for Healthcare Quality.
Percentage of Eligible Members that Receive Preventive Dental Servicesn/aCMS/URAC.
Health Risk Assessment Completion Raten/aURAC.
Use of High Risk Medications in the Elderlyn/aPQA.

The AAAHC documented in its application how its measures and standards comply with the requirements contained in § 156.275. The application also clarifies how AAAHC accreditation complies with § 156.275(c)(2) and (c)(3). Specifically, AAAHC will provide accreditation at the required Exchange product type level, assuming that adequate member numbers and data are available, as required by 45 CFR 156.275(c)(2)(iii).

CMS evaluated AAAHC's application information regarding accreditation survey methodology and processes for scoring and consider the standards to be methodologically rigorous and transparent as required in § 156.275(c)(3). The AAAHC described its health plan scoring methodology for 2013 and documented that the collection and reporting of a required set of clinical quality measures and CAHPS® data will be factored into the overall accreditation score. The majority of AAAHC accreditation standards are rated on a five-point scale of Fully Compliant to Non-Compliant and a critical set of standards must be fully met for successful health plan accreditation, including the reporting of clinical quality measures.

2. Public Comment

This notice solicits public comments on the analysis above and the conclusion that it is appropriate to recognize AAAHC as an accrediting entity for the purpose of QHP certification. We seek specific comments on AAAHC's accreditation standards for QHP issuers including: whether the public believes AAAHC's standards meet the requirements in § 156.275; whether there are any deficiencies in its standards that should be reviewed; the content of the proposed clinical quality measures and their appropriateness for use in QHP accreditation; the rigor of the scoring methodology; and if the network adequacy standards will ensure sufficient network of providers for QHP enrollees.

III. 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.

IV. Response to Comments

Because of the large number of public comments we normally receive on Federal Register documents, we are not Start Printed Page 56714able 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 before making a determination of recognition of an accrediting entity. Upon completion of our analysis, including evaluation of comments received as a result of this notice, we will publish a final notice in the Federal Register announcing the result of our determination. (Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health Care to be a Recognized Accrediting Entity for the Accreditation of Qualified Health Plans)

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Dated: August 29, 2013.

Marilyn Tavenner,

CMS Administrator, Centers for Medicare & Medicaid Services.

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1.  Patient Protection and Affordable Care Act; Data Collection To Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans Final Rule 77 FR 42658, 42662-42668 (July 20, 2012) (45 CFR 156.275(c)).

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2.  Certain authority under the Affordable Care Act has been delegated from the Secretary to the Administrator of CMS., 76 FR 53903 through 53906, (Aug. 30, 2011).

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3.  Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation; Final Rule, 78 FR 12834, 12854-12855 (February 25, 2013)(45 CFR 156.275(c)).

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5.  Interested persons may contact AAAHC to request a copy of the handbook.

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[FR Doc. 2013-22369 Filed 9-12-13; 8:45 am]