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[Federal Register Volume 77, Number 102 (Friday, May 25, 2012)]
[Notices]
[Pages 31364-31366]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-12812]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4164-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. This new term of approval 
would begin May 26, 2012, and end May 25, 2018.

DATES: This final notice is effective May 26, 2012 through May 25, 
2018.

FOR FURTHER INFORMATION CONTACT: Caroline Baker, (410) 786-0116; or 
Edgar Gallardo, (410) 786-0361.

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 riskbearing organization as set forth in 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). Once accredited by such a 
CMS-approved AO, we deem the MA organization to be compliant in one or 
more of six requirements set forth in section 1852(e)(4)(B) of the Act. 
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 Medicare requirements. Health maintenance organizations 
(HMOs) or preferred provider organizations (PPOs) accredited by an 
approved AO may receive, at their request, ``deemed'' status for CMS 
requirements with respect to the following six MA criteria: Quality 
Improvement; Antidiscrimination; Access to Services; Confidentiality 
and Accuracy of Enrollee Records; Information on Advanced Directives; 
and Provider Participation Rules. (See 42 CFR 422.156(b)). At this 
time, recognition of accreditation does not include the Part D areas of 
review set out at Sec.  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

[[Page 31365]]

renew its ``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, 2006, and that term will expire on May 26, 2012. On December 9, 
2011, URAC submitted an application to renew its deeming authority. On 
that same date, URAC submitted materials requested from CMS which 
included updates and/or changes to items set out in Federal regulations 
at Sec.  422.158(a) that are prerequisites for receiving approval of 
its accreditation program from CMS, and which were furnished to CMS by 
URAC as a part of their renewal applications for HMOs and PPOs.

II. Deeming Applications Approval Process

    Section 1865(a)(3)(A) 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. 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 30, 2012, Federal Register (77 FR 19288), we published 
a proposed notice announcing URAC'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 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 organization'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 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.
     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 March 30, 
2012 proposed notice (77 FR 19288) 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 our proposed 
notice.

IV. 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 III of this final notice, and yielded 
the following:
     URAC amended its crosswalk to ensure current URAC 
standards are clearly crosswalked to the following regulatory 
requirements: Sec. Sec.  422.128; 422.206(b)(2); 422.112(a)(1); 
422.112(a)(2); 422.112(a)(8); 422.112(b)(3); 422.112(b)(4)(iii); 
422.112(b)(5); 422.118; 422.152; 422.202(b); and 422.202(c).
     To meet the amendments made at Sec.  422.156 by the final 
rule published in the April 15, 2011 Federal Register (76 CFR 21432), 
URAC removed Quality Improvement Projects and Chronic Care Improvement 
Programs from its deeming process.

B. Term of Approval

    Based on the review and observations described in section III of 
this final notice, we have determined that URAC's accreditation program 
requirements

[[Page 31366]]

meet or exceed our requirements. Therefore, we approve URAC as a 
national accreditation organization with deeming authority for MA HMOs 
and PPOs, effective May 26, 2012 through May 25, 2018.

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. 35).

    Authority:  Section 1865 of the Social Security Act (42 U.S.C. 
1395bb).

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program; No. 93.773 Medicare--Hospital Insurance Program; 
and No. 93.774, Medicare--Supplemental Medical Insurance Program)

    Dated: May 21, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2012-12812 Filed 5-24-12; 8:45 am]
BILLING CODE 4120-01-P
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