[Federal Register Volume 77, Number 62 (Friday, March 30, 2012)]
[Notices]
[Pages 19288-19290]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-7699]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4164-PN]


Medicare Program; 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 & Medicare Services (CMS), HHS.

ACTION: Proposed notice.

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SUMMARY: This notice announces our proposal 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. This notice announces a 
30-day period for public comments on the 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. on April 30, 2012.

ADDRESSES: In commenting, please refer to file code CMS-4164-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 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-4164-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-4164-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

[[Page 19289]]

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) 786-7195 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.

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

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 Web 
site as soon as possible after they have been received: http://www.regulations.gov. 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

    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 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 can be 
``deemed'' compliant in one or more of six 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. 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 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 Sec.  
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 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, 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. 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 
February 6, 2012. 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 in accordance with our 
regulations, and will include but not necessarily be limited to the 
following components:

A. Components of the Review Process

    <bullet> The types of MA plans that it would review as part of its 
accreditation process.
    <bullet> A detailed comparison of the organization's accreditation 
requirements and standards with the Medicare requirements (for example, 
a crosswalk).
    <bullet> 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.
    <bullet> 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.
    <bullet> 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.

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    <bullet> 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.
    <bullet> 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.
    <bullet> 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.
    <bullet> A list of all currently accredited MA organizations and 
the type, category, and expiration date of the accreditation held by 
each of them.
    <bullet> A list of all full and partial accreditation surveys 
scheduled to be performed by the accreditation organization as 
requested by CMS.
    <bullet> The name and address of each person with an ownership or 
control interest in the accreditation organization.
    <bullet> We 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 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 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.

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

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

    Dated: March 23, 2012.
Marilyn Tavenner,
Acting CMS Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2012-7699 Filed 3-29-12; 8:45 am]
BILLING CODE 4120-01-P