Notice2025-08722
Medicare Program; Request for Renewal of Deeming Authority of the Utilization Review Accreditation Commission (URAC) for Medicare Advantage Health Maintenance Organizations and Preferred Provider Organizations
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
May 16, 2025
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This proposed notice announces that the Centers for Medicare & Medicaid Services is considering granting approval of the Utilization Review Accreditation Commission's renewal application for Medicare Advantage "deeming authority" of Health Maintenance Organizations and Preferred Provider Organizations to continue participation in the Medicare or Medicaid program.
Full Text
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<title>Federal Register, Volume 90 Issue 94 (Friday, May 16, 2025)</title>
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[Federal Register Volume 90, Number 94 (Friday, May 16, 2025)]
[Notices]
[Pages 21041-21043]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-08722]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4211-PN]
Medicare Program; Request for Renewal of Deeming Authority of the
Utilization Review Accreditation Commission (URAC) for Medicare
Advantage Health Maintenance Organizations and Preferred Provider
Organizations
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services (HHS).
ACTION: Notice with request for comment.
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SUMMARY: This proposed notice announces that the Centers for Medicare &
Medicaid Services is considering granting approval of the Utilization
Review Accreditation Commission's renewal application for Medicare
Advantage ``deeming authority'' of Health Maintenance Organizations and
Preferred Provider Organizations to continue participation in the
Medicare or Medicaid program.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. June 16, 2025.
ADDRESSES: In commenting, refer to file code CMS-4211-PN.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to <a href="https://www.regulations.gov">https://www.regulations.gov</a>. 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-4211-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-4211-PN, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
FOR FURTHER INFORMATION CONTACT: Dawn Johnson Scott, (410) 786-3159 or
Katie Schenck, (410) 786-0628.
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
website as soon as possible after they have been received: <a href="https://www.regulations.gov">https://www.regulations.gov</a>. Follow the search instructions on that website to
view public comments.
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services through a Medicare Advantage (MA) organization that
contracts with the Center for Medicare & Medicaid Services (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 422.503(b). 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
provisions of the Act include Parts A and B of Title XVIII and Parts A
and E of Title XI of the Act pertaining to the provision of
[[Page 21042]]
services by Medicare-certified providers and suppliers. Generally, for
an entity to be an MAO, the organization must be licensed by the state
as a risk bearing organization, as set forth in 42 CFR 422.400.
As a method of assuring compliance with certain Medicare
requirements, an MAO may choose to become accredited by a CMS-approved
accreditation organization (AO). By virtue of its accreditation by a
CMS-approved AO, the MAO may be ``deemed'' compliant in one or more
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, as set forth in Sec.
422.157(a)(1), prove to CMS that their standards are at least as
stringent as Medicare requirements for MAOs. MAOs that are licensed as
health maintenance organizations (HMOs) or preferred provider
organizations (PPOs) and are accredited by an approved AO may receive,
at their request, ``deemed'' status for CMS requirements for the
deemable areas. These areas include Quality Improvement, Anti-
Discrimination, Confidentiality and Accuracy of Enrollee Records,
Information on Advance Directives, and Provider Participation Rules.
At this time, CMS does not recognize accreditation of the following
areas: Access to Services set out in Sec. 422.156(b)(3) or the Part D
areas of review set out at Sec. 423.165(b) as part of the MA deeming
program. 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
previously approved by CMS as an accreditation organization for MA
deeming of HMOs and PPOs for a term from May 31, 2019 to June 2, 2025.
On March 14, 2025, URAC submitted its initial application to renew its
deeming authority, including materials requested by CMS that included
information intended to address the requirements set out in regulations
at Sec. 422.158(a) and (b) that are prerequisites for receiving
approval of its accreditation program from CMS. CMS subsequently
requested that additional materials be submitted by URAC to satisfy
these requirements.
II. Provisions of the Proposed Notice
This proposed notice notifies the public of URAC's request to renew
its MA 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 submitted on March 14, 2025, and CMS has determined the
application is complete. Under section 1852(e)(4) of the Act and Sec.
422.158 (Federal review of accreditation organizations), our review and
evaluation of URAC will be conducted as discussed below.
A. Components of the Review Process
The review of URAC's renewal application for approval of MA deeming
authority includes, but is not limited to, the following components:
<bullet> The types of MA plans that it would review as part of its
accreditation process.
<bullet> A detailed comparison of URAC's accreditation requirements
and standards with the Medicare requirements (for example, a crosswalk)
in the following 5 deemable areas: Quality Improvement, Anti-
Discrimination, Confidentiality and Accuracy of Enrollee Records,
Information on Advance Directives, and Provider Participation Rules.
<bullet> 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.
++ Descriptions of--
--The survey review process and the accreditation status decision
making process.
--The procedures used to notify accredited MAOs 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 AO, 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; and
++ The organization's policies and practice for 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 for its surveys and accreditation decisions, including
the kinds of reports, tables, and other displays generated by that
system.
<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 for the withholding or removal of accreditation for failure
to meet the AO'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 AO.
<bullet> A list of all currently accredited MAOs 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 AO.
<bullet> The name and address of each person with an ownership or
control interest in the AO.
<bullet> CMS will also consider URAC's past performance in the
deeming program and results of recent deeming validation reviews or
equivalency reviews 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 a review of comments
received as a result of this proposed 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
[[Page 21043]]
manner. The Act provides us with 210 calendar days after the date of
receipt of a completed application to complete our survey activities
and application review process. Within the 210-day period, we will
publish an approval or denial of the application in the Federal
Register.
III. Collection of Information Requirements
This document does not impose any new or revised ``collection of
information'' requirements or burden. Consequently, there is no need
for review by the Office of Management and Budget under the authority
of the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501 et seq.).
With respect to the PRA and this section of the preamble, collection of
information is defined under 5 CFR 1320.3(c) of the PRA's implementing
regulations.
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.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Mehmet Oz, having reviewed and approved this document,
authorizes Trenesha Fultz-Mimms, who is the Federal Register Liaison,
to electronically sign this document for purposes of publication in the
Federal Register.
Trenesha Fultz-Mimms,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2025-08722 Filed 5-14-25; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on May 16, 2025.
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