[Federal Register Volume 78, Number 178 (Friday, September 13, 2013)]
[Pages 56711-56714]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-22369]



Centers for Medicare & Medicaid Services


Health Insurance Exchanges; Application by the Accreditation 
Association for Ambulatory Health Care To Be a Recognized Accrediting 
Entity for the Accreditation of Qualified Health Plans

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.


SUMMARY: This notice announces the receipt of an application from the 
Accreditation Association for Ambulatory Health Care (AAAHC) to be a 
recognized accrediting entity for the purposes of fulfilling the 
accreditation requirement as part of qualified health plan (QHP) 
certification. Regulations require HHS to publish a notice identifying 
the accrediting entity, summarizing its analysis of whether the 
accrediting entity meets certain criteria, and providing no less than a 
30-day public comment period.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on October 15, 2013.

ADDRESSES: In commenting, please refer to file code CMS-9953-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-9953-PN, P.O. Box 8010, 
Baltimore, MD 21244-8010.
    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-9953-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 
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
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) 786-9994 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 

FOR FURTHER INFORMATION CONTACT: Rebecca Zimmermann, at (301) 492-4396.

    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

    Regulations at 45 CFR 156.275 require qualified health plan (QHP) 
issuers to be accredited on the basis of local performance of its QHPs 
by an accrediting entity recognized by the Department of Health and 
Human Services (HHS). In a final rule published on July 20, 2012,\1\ we 
established the first phase of an intended two-phase approach to 
recognize accrediting entities and proposed both the National Committee 
for Quality Assurance (NCQA) and URAC as recognized accrediting 
entities. On November 23, 2012, we notified the public that NCQA and 
URAC had both met the requirements in the final rule to be recognized 
as an accrediting entity (77 FR 42662 through 42668) and were 
recognized by the Secretary \2\ as accrediting entities for the 
purposes of QHP certification.

    \1\ Patient Protection and Affordable Care Act; Data Collection 
To Support Standards Related to Essential Health Benefits; 
Recognition of Entities for the Accreditation of Qualified Health 
Plans Final Rule 77 FR 42658, 42662-42668 (July 20, 2012) (45 CFR 
    \2\ Certain authority under the Affordable Care Act has been 
delegated from the Secretary to the Administrator of CMS., 76 FR 
53903 through 53906, (Aug. 30, 2011).

    On February 25, 2013, we published a subsequent final rule title, 
``Standards Related to Essential Health Benefits, Actuarial Value, and 
Accreditation (78 FR 1283),'' \3\ which amended Sec.  156.275(c) to 
establish an application and review process to allow additional

[[Page 56712]]

accrediting entities to seek recognition. The application submitted by 
an accrediting entity must include documentation described in Sec.  
156.275(c)(4) and demonstrate, in a concise and organized fashion how 
the accrediting entity meets the requirements of Sec.  156.275 (c)(2) 
and (3). Specifically, to be recognized, an accrediting entity must 
provide current accreditation standards and requirements, processes and 
measure specifications for performance measures to demonstrate via a 
crosswalk that it meets the conditions described in Sec.  156.275 
(c)(2) and (c)(3). Further, once recognized, Sec.  156.275(c)(4)(ii) 
requires accrediting entities to provide the Secretary with any 
proposed changes or updates to the accreditation standards and 
requirements, processes, and measure specifications for performance 
measures with 60 days' notice prior to public notification. Lastly, 
Sec.  156.275(c)(5) requires recognized accrediting entities, when 
authorized by an accredited QHP issuer, to provide specific QHP issuer 
accreditation survey data elements to the Exchange.

    \3\ Patient Protection and Affordable Care Act; Standards 
Related to Essential Health Benefits, Actuarial Value, and 
Accreditation; Final Rule, 78 FR 12834, 12854-12855 (February 25, 
2013)(45 CFR 156.275(c)).

II. Provisions of the Notice

    The purpose of this notice is to notify the public of the 
Accreditation Association for Ambulatory Health Care's (AAAHC) request 
for recognition by the Secretary as an accrediting entity for the 
purposes of QHP certification. As part of the application, AAAHC 
submitted all the required documentation materials described in Sec.  
156.275(c)(4). Below we present, our analysis of whether AAAHC meets 
the criteria described in paragraphs Sec.  156.275 (c)(2) and (3).

1. Summary of CMS's Analysis

    We are providing the public with an analysis of AAAHC's completed 
application, including a review of the current accreditation standards 
and requirements, processes and measure specifications for performance 
measures, submitted by AAAHC. Currently, AAAHC is an accrediting body 
that has a CMS-approved accreditation program to conduct surveys for 
ambulatory surgery centers that wish to participate in the Medicare 
program with deemed status. The AAAHC has also obtained approval from 
CMS as a deeming entity allowing it to survey Medicare Advantage 
plans.\4\ The current scope of accreditation as described in AAAHC's 
2013 Accreditation Handbook for Health Plans demonstrates that AAAHC 
will be providing accreditation of QHPs within the statutorily required 
categories,\5\ established in Sec.  156.275(c), including reporting on 
a set of clinical quality measures and patient experience ratings on a 
standardized Consumer Assessment of Healthcare Providers and Systems 
(CAHPS[supreg]) survey; consumer access; utilization management; 
quality assurance; provider credentialing; complaints and appeals; 
network adequacy and access; and patient information programs.

    \4\ 42 CFR 422.157.
    \5\ Interested persons may contact AAAHC to request a copy of 
the handbook.

    In addition, CMS evaluated AAAHC's standards relating to network 
adequacy and consider them to be consistent with the general 
requirements for network adequacy for QHP issuers (45 CFR 156.230(a)(2) 
and (3)). To determine health plans' compliance with network adequacy 
standards, the AAAHC accreditation survey includes review of areas such 
as member choice of providers, member satisfaction with relation to 
provider access, availability of services, provider network 
credentialing and customer complaints, appeals, and satisfaction 
    Upon review of the clinical quality measures included in AAAHC's 
accreditation standards, we have assessed that the measures cover a 
range of conditions and domains, include adult and child-specific 
measures, align with the priorities in the National Strategy for 
Quality Improvement in Health Care, are developed or adopted by the 
National Quality Forum (NQF) or are in common use for health plan 
quality measurement, and meet health plan industry standards and are 
evidence-based, as required in Sec.  156.275(c)(2)(ii). The following 
list displays the clinical quality measures that will be used for QHP 
accreditation by AAAHC, spanning preventive care, behavioral health and 
substance abuse disorders, chronic care, and acute care:

                                     NQF reference    Measure develop/
              Measure                     No.              steward
                           Mandatory Measures
Proportion of Days Covered (Drug              0541  Pharmacy Quality
 Therapy.                                            Alliance (PQA).
Provider Network Adequacy--Number              n/a  Centers for Medicare
 of Specialists Accepting New                        and Medicaid
 Patients At End of Reporting                        Services (CMS).
 Period by Specialist Type.
Dyslipidemia New Medication 12-                n/a  Resolution Health,
 Week Testing.                                       Inc.
Drug-Drug Interactions............             n/a  PQA.
Diabetes Short Term Complications             0272  Adapted by URAC from
 Event.                                              Agency for
Rate..............................                   Healthcare Quality
                                                     and Research (AHRQ)
Diabetes Long Term Complications              0274  Adapted by URAC from
 Admission Rate.                                     AHRQ measure.
Adult Asthma Event Rate...........            0283  Adapted by URAC from
                                                     AHRQ measure.
Pediatric Asthma Event Rate.......             n/a  Adapted by URAC from
                                                     AHRQ measure.
                      Mandatory/Equivalent Measures
Atherosclerotic Disease--Lipid                0616  Active Health
 Panel Monitoring.                                   Management.
Diabetes All-Or-None Process                   n/a  Wisconsin
 Measure (HbA1c, LDL-C,                              Collaborative for
 Nephropathy).                                       Healthcare Quality.
Provider Network Adequacy--Primary             n/a  CMS.
Medication Therapy For Patients               0548  PQA.
 With Asthma: Suboptimal Asthma
 Control (SAC), and Absence of
 Controller Therapy (ACT).
Call Center Performance...........             n/a  URAC.
Percentage of Live Births Weighing            0278  AHRQ.
 Less than 2,500 Grams.

[[Page 56713]]

Annual Percentage of Asthma                   1381  Alabama Medicaid.
 Patients 2 through 20 Years Old
 with One or More Asthma-related
 Emergency Room Visits.
Percentage of Female Patients Who              n/a  American Medical
 Had a Mammogram Performed During                    Association/
 the Two-Year Measurement Period.                    Physician
                                                     Improvement (AMA/
High Risk for Pneumococcal                    0617  ActiveHealth
 Disease--Pneumococcal Vaccination.                  Management.
Preventive Services: Percentage of             n/a  American Academy of
 Enrolled Members Ages Less than                     Pediatrics/URAC.
 or Equal to 18 years Who have had
 Preventive Services, Recommended
 Risk Factor Reductions and
 Behavioral Health Change
 Interventions, Appropriate
 Screenings and Immunizations.
Colorectal Cancer Screening.......             n/a  Veterans Health
Tobacco Use: Screening and                    0028  AMA/PCPI/URAC.
Prevention and Management of                   n/a  Institute for
 Obesity in Mature Adolescents and                   Clinical Systems
 Adults.                                             Improvement(ICSI)/
30 Day Post-Hospital AMI Discharge            0698  Centers for Medicare
 Care Transition Composite Measure.                  and Medicaid
                                                     Services (CMS)/
Congestive Heart Failure (CHF)                0358  AHRQ/URAC.
Atrial Fibrillation--Warfarin                 0264  ActiveHealth
 Therapy.                                            Management.
MRI Lumbar Spine for Low Back Pain            0514  CMS.
All Cause Readmission Index.......            0505  United Health Group/
Central Venous Catheter-related                n/a  AHRQ.
 Bloodstream Infections (area-
 level): Rate per 100,000
Depression Readmission............             n/a  Minnesota Community
Follow-up After Hospitalization                n/a  Florida Agency for
 for a Mental Illness.                               Health Care
CAHPS[supreg] Adult Health Plan               0006  AHRQ.
 Survey 5.0.
CAHPS[supreg] Child Survey v4.0                n/a  AHRQ.
 Medicaid and Commercial Core
CAHPS[supreg] Survey for Children             0009  AHRQ.
 With Chronic Conditions.
                          Exploratory Measures
Case Management: Consumer Contact.             n/a  URAC.
Complaint Response Timeliness.....             n/a  URAC.
Outpatient Newborn Visit Within                n/a  Centene.
 One Month of Birth.
Diabetes: All or None Process                  n/a  Wisconsin
 Measure: Optimal Results for                        Collaborative for
 HbA1c, LDL-C, and Blood Pressure.                   Healthcare Quality.
Percentage of Eligible Members                 n/a  CMS/URAC.
 that Receive Preventive Dental
Health Risk Assessment Completion              n/a  URAC.
Use of High Risk Medications in                n/a  PQA.
 the Elderly.

    The AAAHC documented in its application how its measures and 
standards comply with the requirements contained in Sec.  156.275. The 
application also clarifies how AAAHC accreditation complies with Sec.  
156.275(c)(2) and (c)(3). Specifically, AAAHC will provide 
accreditation at the required Exchange product type level, assuming 
that adequate member numbers and data are available, as required by 45 
CFR 156.275(c)(2)(iii).
    CMS evaluated AAAHC's application information regarding 
accreditation survey methodology and processes for scoring and consider 
the standards to be methodologically rigorous and transparent as 
required in Sec.  156.275(c)(3). The AAAHC described its health plan 
scoring methodology for 2013 and documented that the collection and 
reporting of a required set of clinical quality measures and 
CAHPS[supreg] data will be factored into the overall accreditation 
score. The majority of AAAHC accreditation standards are rated on a 
five-point scale of Fully Compliant to Non-Compliant and a critical set 
of standards must be fully met for successful health plan 
accreditation, including the reporting of clinical quality measures.

2. Public Comment

    This notice solicits public comments on the analysis above and the 
conclusion that it is appropriate to recognize AAAHC as an accrediting 
entity for the purpose of QHP certification. We seek specific comments 
on AAAHC's accreditation standards for QHP issuers including: whether 
the public believes AAAHC's standards meet the requirements in Sec.  
156.275; whether there are any deficiencies in its standards that 
should be reviewed; the content of the proposed clinical quality 
measures and their appropriateness for use in QHP accreditation; the 
rigor of the scoring methodology; and if the network adequacy standards 
will ensure sufficient network of providers for QHP enrollees.

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

[[Page 56714]]

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 before making a determination of recognition 
of an accrediting entity. Upon completion of our analysis, including 
evaluation of comments received as a result of this notice, we will 
publish a final notice in the Federal Register announcing the result of 
our determination. (Health Insurance Exchanges; Application by the 
Accreditation Association for Ambulatory Health Care to be a Recognized 
Accrediting Entity for the Accreditation of Qualified Health Plans)

    Dated: August 29, 2013.
Marilyn Tavenner,
CMS Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2013-22369 Filed 9-12-13; 8:45 am]