evekhm/cms_iom_500 huggingface dataset:
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care provider and to enrollees who have been patients of that primary care or behavioral health provider within the past three years. (2) For contract terminations that involve specialty types other than primary care or behavioral health: (i) Provide written notice, (ii) At least 30 calendar days before the termination effective date, and (iii) To all enrollees who are patients seen on a regular basis by the provider whose contract is terminating. The phrase enrollees who are patients seen on a regular basis by the provider whose contract is terminating means enrollees who are assigned to, currently receiving care from, or have received care within VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00211 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222330 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations the past three months from a provider or facility being terminated. * * * * * 9. Section 422.112 is amended by a. Adding a sentence at the end of paragraph (a)(1)(i); b. Adding paragraph (a)(1)(iii); c. Removing the last sentence of paragraph (a)(3); d. Revising paragraphs (a)(6)(i), (a)(8) and (b)(3); and e. Adding paragraph (b)(8). The additions and revisions read as follows:  422.112 Access to services. (a) * * * (1) * * * (i) * * * The network must include providers that specialize in behavioral health services. * * * * * (iii) Arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollees medical needs. * * * * * (6) * * * (i) Timeliness of access to care and member services that meet or exceed standards in this paragraph. The MA organization must continuously monitor access to care and member services and must take corrective action
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* * * * * (6) * * * (i) Timeliness of access to care and member services that meet or exceed standards in this paragraph. The MA organization must continuously monitor access to care and member services and must take corrective action as necessary to ensure that appointment wait times in the provider network comply with these standards. The minimum standards for appointment wait times for primary care and behavioral health services are as follows for appointments: (A) Urgently needed services or emergencyimmediately; (B) Services that are not emergency or urgently needed, but the enrollee requires medical attentionwithin 7 business days; and (C) Routine and preventive care within 30 business days. * * * * * (8) Ensuring equitable access to Medicare Advantage (MA) Services. Ensure that services are provided in a culturally competent manner and to promote equitable access to all enrollees, including the following: (i) People with limited English proficiency or reading skills. (ii) People of ethnic, cultural, racial, or religious minorities. (iii) People with disabilities. (iv) People who identify as lesbian, gay, bisexual, or other diverse sexual orientations. (v) People who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex. (vi) People living in rural areas and other areas with high levels of deprivation. (vii) People otherwise adversely affected by persistent poverty or inequality. * * * * * (b) * * * (3) Programs for coordination of plan services with community and social services generally available through contracting or noncontracting providers in the area served by the MA plan, including nursing home and community-based services, and behavioral health services; and * * * * * (8)(i) With respect to basic benefits, policies for using prior authorization that at a minimum include that for enrollees undergoing an active course of treatment (A) Approval of a prior authorization request for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care, in accordance with applicable coverage criteria, the individual patients medical history, and the treating providers recommendation; and (B) A minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider. This
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A minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider. This includes enrollees new to a plan and enrollees new to Medicare. The MA organization must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days. (ii) For purposes of this paragraph (b)(8), the following definitions apply: (A) Course of treatment means as a prescribed order or ordered course of treatment for a specific individual with a specific condition is outlined and decided upon ahead of time with the patient and provider. A course of treatment may but is not required to be part of a treatment plan. (B) Active course of treatment means a course of treatment in which a patient is actively seeing the provider and following the course of treatment. * * * * * 10. Section 422.113 is amended by revising paragraph (b)(1)(i) introductory text to read as follows:  422.113 Special rules for ambulance services, emergency and urgently needed services, and maintenance and post- stabilization care services. * * * * * (b) * * * (1) * * * (i) Emergency medical condition means a medical condition, mental or physical, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in * * * * * 11. Section 422.116 is amended by a. In paragraph (a)(1)(i), removing  422.114(a)(3)(ii) and adding  422.2 in its place; b. Adding paragraphs (b)(1)(xxviii) and (xxix); c. Adding in alphabetical order entries for Clinical Psychology, and Licensed Clinical Social Work to Table 1 to Paragraph (d)(2); d. Adding paragraphs (d)(5)(xiii) and (xxiv); and e. Adding in alphabetical order entries for Clinical Psychology, and
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1 to Paragraph (d)(2); d. Adding paragraphs (d)(5)(xiii) and (xxiv); and e. Adding in alphabetical order entries for Clinical Psychology, and Clinical Social Work to Table 2 to Paragraph (e)(3)(i)(C). The revisions and additions read as follows:  422.116 Network adequacy. * * * * * (b) * * * (1) * * * (xxviii) Clinical Psychology. (xxix) Clinical Social Work. * * * * * (d) * * * (2) * * * VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00212 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222331 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations * * * * * (5) * * * (xiii) Clinical Psychology. (xxiv) Clinical Social Work. * * * * * (e) * * * (3) * * * (i) * * * (C) * * * * * * * * 12. Section 422.137 is added to read as follows:  422.137 Medicare Advantage Utilization Management Committee. (a) General. An MA organization that uses utilization management (UM) policies and procedures, including prior authorization (PA), must establish a UM committee that is led by a plans medical director (described in  422.562(a)(4)). (b) Limit on use of UM policies and procedures. An MA plan may not use any UM policies and procedures for basic or supplemental benefits on or after January 1, 2024 unless those policies and procedures have been reviewed and approved by the UM committee. (c) Utilization Management Committee Composition. The UM committee must (1) Include a majority of members who are practicing physicians. (2) Include at least one practicing physician who is independent and free of conflict relative to the MA organization and MA plan. (3) Include at least one practicing physician who is an expert regarding care of elderly or disabled
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members who are practicing physicians. (2) Include at least one practicing physician who is independent and free of conflict relative to the MA organization and MA plan. (3) Include at least one practicing physician who is an expert regarding care of elderly or disabled individuals. (4) Include members representing various clinical specialties (for example, primary care, behavioral health) to ensure that a wide range conditions are adequately considered in the development of the MA plans utilization management policies. (d) Utilization Management Committee Responsibilities. The UM committee must (1) At least annually, review the policies and procedures for all utilization management, including prior authorization, used by the MA plan. Such review must consider: (i) The services to which the utilization management applies; (ii) Coverage decisions and guidelines for Traditional Medicare, including NCDs, LCDs, and laws; and (iii) Relevant current clinical guidelines. (2) Approve only utilization management policies and procedures that: (i) Use or impose coverage criteria that comply with the requirements and standards at  422.101(b); (ii) For prior authorization policies, comply with requirements and standards at  422.138; (iii) Comply with the standards in  422.202(b)(1); and (iv) Apply and rely on medical necessity criteria that comply with  422.101(c)(1). (3) Revise the utilization management policies and procedures as necessary to comply with the standards in this regulation, including removing requirements for UM for services and items that no longer warrant UM. (4) Clearly articulate and document processes to determine that the requirements under paragraphs (c)(1) through (4) of this section have been met, including the determination by an objective party of whether disclosed financial interests are conflicts of interest and the management of any recusals due to such conflicts. (5) Document in writing the reason for its decisions regarding the development of UM policies and make this documentation available to CMS upon request. 13. Section 422.138 is added to read as follows:  422.138 Prior authorization. (a) Requirement. When a coordinated care plan, as specified in  422.4(a)(iii) (including MSA network plans), uses prior authorization processes in connection with basic benefits or supplemental benefits, the MA organization must comply with the requirements in this section. (MA PFFS are not permitted to use prior authorization policies or
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(including MSA network plans), uses prior authorization processes in connection with basic benefits or supplemental benefits, the MA organization must comply with the requirements in this section. (MA PFFS are not permitted to use prior authorization policies or prior notification policies that reduce cost sharing for enrollees based on whether the enrollee or provider notifies the PFFS plan in advance that services will be furnished). Prior authorization processes include all policies and procedures used in prior authorization unless otherwise noted. (b) Application. Prior authorization processes for coordinated care plans may only be used for one or more the following purposes: VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00213 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ER12AP23.022</GPH> ER12AP23.023</GPH>ddrumheller on DSK120RN23PROD with RULES222332 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations (1) To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or (2) For basic benefits, to ensure an item or service is medically necessary based on standards specified in  422.101(c)(1), or (3) For supplemental benefits, to ensure that the furnishing of a service or benefit is clinically appropriate. (c) Effect of prior authorization or pre- service approval. If the MA organization approved the furnishing of a covered item or service through a prior authorization or pre-service determination of coverage or payment, it may not deny coverage later on the basis of lack of medical necessity and may not reopen such a decision for any reason except for good cause (as provided at  405.986 of this chapter) or if there is reliable evidence of fraud or similar fault per the reopening provisions at  422.616. The definitions of the terms reliable evidence and similar fault in  405.902 of this chapter apply to this provision. 14. Section 422.152 is amended by adding paragraph (a)(5) to read as follows:  422.152 Quality Improvement
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and similar fault in  405.902 of this chapter apply to this provision. 14. Section 422.152 is amended by adding paragraph (a)(5) to read as follows:  422.152 Quality Improvement Program. (a) * * * (5) Incorporate one or more activities that reduce disparities in health and health care. These activities must be broadly accessible irrespective of race, ethnicity, national origin, religion, sex, or gender. These activities may be based upon health status and health needs, geography, or factors not listed in the previous sentence only as appropriate to address the relevant disparities in health and health care. * * * * * 15. Section 422.162 is amended by a. In paragraph (a) adding in alphabetical order a definition for health equity index and a revision to the definition of highly-rated contract; and b. Revising paragraphs (b)(1) and (b)(3)(iv)(A)(1). The addition and revisions read as follows:  422.162 Medicare Advantage Quality Rating System. (a) * * * Health equity index means an index that summarizes contract performance among those with specified social risk factors (SRFs) across multiple measures into a single score. * * * * * Highly-rated contract means a contract that has 4 or more stars for its highest rating when calculated without the improvement measures and with all applicable adjustments in  422.166(f). * * * * * (b) * * * (1) General. CMS calculates an overall Star Rating, Part C summary rating, and Part D summary rating for each MAPD contract, and a Part C summary rating for each MA-only contract using the 5-star rating system described in this subpart. Measures are assigned stars at the contract level and weighted in accordance with  422.166(a). Domain ratings are the unweighted mean of the individual measure ratings under the topic area in accordance with  422.166(b). Summary ratings are the weighted mean of the individual measure ratings for Part C or Part D in accordance with  422.166(c), with the applicable adjustments provided in paragraph (f) of this section. Overall Star Ratings are calculated by using the weighted mean of the individual measure ratings in accordance with
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ratings for Part C or Part D in accordance with  422.166(c), with the applicable adjustments provided in paragraph (f) of this section. Overall Star Ratings are calculated by using the weighted mean of the individual measure ratings in accordance with  422.166(d), with the applicable adjustments provided in paragraph (f) of this section. CMS includes the Star Ratings measures in the overall and summary ratings that are associated with the contract type for the Star Ratings year. * * * * * (3) * * * (iv) * * * (A)(1) For the first year after consolidation, CMS uses enrollment- weighted measure scores using the July enrollment of the measurement period of the consumed and surviving contracts for all measures, except survey-based measures, call center measures, and improvement measures. The survey- based measures will use enrollment of the surviving and consumed contracts at the time the sample is pulled for the rating year. The call center measures will use average enrollment during the study period. The Part C and D improvement measures are not calculated for first year consolidations. * * * * * 16. Section 422.164 is amended by adding paragraph (e)(1)(iii) to read as follows:  422.164 Adding, updating, and removing measures. * * * * * (e) * * * (1) * * * (iii) The measure steward other than CMS retires a measure. * * * * * 17. Section 422.166 is amended by a. Revising paragraphs (a)(2)(i), (c)(1), (d)(1), (e)(1)(iii) and (iv), (f)(1) introductory text, and (f)(2)(i) introductory text; b. Adding paragraph (f)(3); and c. Revising paragraphs (g)(1), (i)(3)(iv), (i)(9)(i), and (i)(10)(i). The revisions and addition read as follows:  422.166 Calculation of Star Ratings. (a) * * * (2) * * * (i) The method maximizes differences across the star categories and minimizes the differences within star categories using mean resampling with the hierarchal
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Calculation of Star Ratings. (a) * * * (2) * * * (i) The method maximizes differences across the star categories and minimizes the differences within star categories using mean resampling with the hierarchal clustering of the current years data. Effective for the Star Ratings issued in October 2023 and subsequent years, prior to applying mean resampling with hierarchal clustering, Tukey outer fence outliers are removed. Effective for the Star Ratings issued in October 2022 and subsequent years, CMS will add a guardrail so that the measure-threshold-specific cut points for non-CAHPS measures do not increase or decrease more than the value of the cap from 1 year to the next. The cap is equal to 5 percentage points for measures having a 0 to 100 scale (absolute percentage cap) or 5 percent of the restricted range for measures not having a 0 to 100 scale (restricted range cap). New measures that have been in the Part C and D Star Rating program for 3 years or less use the hierarchal clustering methodology with mean resampling with no guardrail for the first 3 years in the program. * * * * * (c) * * * (1) CMS will calculate the Part C summary ratings using the weighted mean of the measure-level Star Ratings for Part C, weighted in accordance with paragraph (e) of this section and with the applicable adjustments provided in paragraph (f) of this section. * * * * * (d) * * * (1) The overall rating for a MAPD contract will be calculated using a weighted mean of the Part C and Part D measure-level Star Ratings, weighted in accordance with paragraph (e) of this section and with the applicable adjustments provided in paragraph (f) of this section. * * * * * (e) * * * (1) * * * (iii) Through the 2025 Star Ratings, patient experience and complaint measures receive a weight of 4. Starting with the 2026 Star Ratings and subsequent Star Ratings years, patient experience and complaint measures receive a weight of 2. VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00214 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on
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Apr 11, 2023 Jkt 259001 PO 00000 Frm 00214 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222333 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations (iv) Through the 2025 Star Ratings, access measures receive a weight of 4. Starting with the 2026 Star Ratings and subsequent Star Ratings years, access measures receive a weight of 2. * * * * * (f) * * * (1) Reward factor. Through the 2026 Star Ratings, this rating-specific reward factor is added to both the summary and overall ratings of contracts that qualify for this reward factor based on both high and stable relative performance for the rating level. * * * * * (2) * * * (i) The CAI is added to or subtracted from the contracts overall and summary ratings and is applied after the reward factor adjustment described in paragraph (f)(1) of this section (if applicable). * * * * * (3) Health equity index. Starting with the 2027 Star Ratings year and subsequent Star Ratings years, CMS applies a health equity index rating- specific factor to both the summary and overall ratings of contracts that qualify based on an assessment of contract performance on quality measures among enrollees with certain social risk factors (SRFs). (i) The health equity index (HEI) is calculated separately for the overall rating for MAPDs and cost contracts including the applicable Part C and D measures; Part C summary rating for MA-only, MAPD, and cost contracts including the applicable Part C measures; Part D summary rating for MAPDs and cost contracts including the applicable Part D measures; and Part D summary rating for PDPs including the applicable Part D measures. (A) The SRFs included in the HEI are receipt of the low income subsidy or being dually eligible for Medicare and Medicaid (LIS/DE), or having a disability. Enrollees will be identified as LIS/DE or as having a disability as specified in paragraph (f)(2)(i)(B) of this section. If a person meets the LIS/DE criteria for only one of the two measurement years included in the
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LIS/DE or as having a disability as specified in paragraph (f)(2)(i)(B) of this section. If a person meets the LIS/DE criteria for only one of the two measurement years included in the HEI, the data for that person for just that year are used. Measures that are case-mix adjusted in the Star Ratings are adjusted using all standard case-mix adjustors for the measure except for those adjusters that are the SRFs of interest in the index, are strongly correlated with the SRFs of interest, or are conceptually similar to the SRFs of interest. (B) The HEI is calculated by combining measure-level scores for the subset of enrollees with SRFs of interest included in the HEI across the two most recent measurement years using a modeling approach that includes year as an adjustor to account for potential differences in performance across years and to adjust the data to reflect performance in the second of the 2 years of data used. Measure-level scores are used for contracts that have data for only the most recent year of the 2 years, but measure-level scores are not used for contracts that have data for only the first of the 2 years. (ii) In determining the HEI scores, a measure will be excluded from the calculation of the index if the measure meets any of the following: (A) The focus of the measurement is not the enrollee but rather the plan or provider. (B) The measure is retired, moved to display, or has a substantive specification change in either year of data used to construct the HEI. (C) The measure is applicable only to SNPs. (D) At least 25 percent of contracts are unable to meet the criteria specified in paragraph (f)(3)(iv) of this section. For Part D measures, this criterion is assessed separately for MAPDs and cost contracts, and for PDPs. (iii) The Star Ratings measures that remain after the exclusion criteria in paragraph (f)(3)(ii) of this section have been applied will be included in the calculation of the HEI. CMS will announce the measures being evaluated for inclusion in the calculation of the HEI under this paragraph (f)(3) through the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act. (iv) For a measure to be included in the calculation of