Notice2025-17037
Medicare Program; Approved Renewal of Deeming Authority of the Utilization Review Accreditation Commission (URAC) for Medicare Advantage Health Maintenance Organizations and Local 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
September 5, 2025
Effective
October 13, 2025
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This final notice announces the Centers for Medicare & Medicaid Services decision to renew the Utilization Review Accreditation Commission's application for Medicare Advantage "deeming authority" of Health Maintenance Organizations and Preferred Provider Organizations for a term of 6 years.
Full Text
<html>
<head>
<title>Federal Register, Volume 90 Issue 170 (Friday, September 5, 2025)</title>
</head>
<body><pre>
[Federal Register Volume 90, Number 170 (Friday, September 5, 2025)]
[Notices]
[Pages 42971-42972]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-17037]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4211-FN]
Medicare Program; Approved Renewal of Deeming Authority of the
Utilization Review Accreditation Commission (URAC) for Medicare
Advantage Health Maintenance Organizations and Local Preferred Provider
Organizations
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final notice.
-----------------------------------------------------------------------
SUMMARY: This final notice announces the Centers for Medicare &
Medicaid Services decision to renew the Utilization Review
Accreditation Commission's application for Medicare Advantage ``deeming
authority'' of Health Maintenance Organizations and Preferred Provider
Organizations for a term of 6 years.
DATES:
Effective Date: The notice is effective on October 13, 2025.
Applicability Date: The approval communicated in this notice is
applicable July 10, 2025 through July 10, 2031.
FOR FURTHER INFORMATION CONTACT: Dawn Johnson Scott, (410) 786-3159 or
Katie Schenck, (410) 786-0628.
SUPPLEMENTARY INFORMATION:
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. Generally, for an entity
to be an MAO, the organization must be licensed under State law, or
otherwise authorized to operate under State law, 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 our 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, we do 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 specified 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 us that included
information intended to address the requirements set out in regulations
at Sec. Sec. 422.158(a) and (b) that are prerequisites for receiving
approval of its accreditation program.
II. Provisions of the Proposed Notice
In the May 16, 2025 Federal Register (90 FR 21041), we published a
proposed notice announcing URAC's request to renew its Medicare
Advantage deeming authority for HMOs and PPOs. In the May 16, 2025
proposed notice, we detailed our evaluation criteria. Under section
1852(e)(4) of the Act and 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:
<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 five deemable areas: (1) Quality Improvement; (2)
Anti-Discrimination; (3) Confidentiality and Accuracy of Enrollee
Records; (4) Information on Advance Directives; and (5) 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.
[[Page 42972]]
--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.
++ 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 approve
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 also considered 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).
In accordance with section 1865(a)(3)(A) of the Act, the May 16,
2025 proposed notice 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.
III. Analysis of and Responses to Public Comments on the Proposed
Notice
We received no public comments on the 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 our continued approval were
conducted as described in section II. of this final notice, and yielded
the following:
<bullet> Under Sec. 422.158(a)(2), URAC submitted a crosswalk and
standards that clearly cross-walked to our regulations, and any
applicable oversight protocols, in each of five deemable areas: (1)
Quality Improvement; (2) Anti-discrimination; (3) Confidentiality and
Accuracy of Enrollee Records; (4) Information on Advance Directives:
and (5) Provider Participation rules.
<bullet> URAC submitted additional information and/or documentation
regarding its survey process that was intended to address our
regulations at Sec. Sec. 422.158(a)(1) through (11), and (b)(1)
through (3).
B. Term of Approval
Based on the review and observations described in section II. of
this final notice, we have determined that URAC's accreditation program
requirements meet or exceed our requirements. Therefore, we approved
URAC as a national accreditation organization with deeming authority
for MA HMOs and PPOs on July 10, 2025 for a term of approval to
continue through July 10, 2031. We informed URAC of their renewal via a
letter dated July 10, 2025.
V. Collection of Information Requirements
This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).
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. 2025-17037 Filed 9-4-25; 8:45 am]
BILLING CODE 4120-01-P
</pre></body>
</html>Indexed from Federal Register on September 5, 2025.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.