Medicare Advantage (MA) Deeming Program Overview

40 – Medicare Advantage (MA) Deeming Program Overview (Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 42 CFR §422.156, 422.157, 422.158 Under section 1852(e)(4) of the Act, CMS established and oversees a program which allows private, national accrediting organizations (AOs) to deem compliance with certain Medicare requirements. The AOs may only grant deemed status for MAOs that it has fully accredited (and periodically re-accredited). Accreditation is an evaluative process (usually involving both on and off site surveys) in which a health care organization chooses to undergo an examination of its policies, procedures and performance by an external organization (“accrediting body”). . In addition to the standard accreditation process, an MAO may pay an additional fee to have the AO conduct various reviews that allow the AO to “deem” that the MAO is compliant with certain Medicare requirements. To deem an MAO, the AO must use standards (and the process for monitoring compliance) that CMS determines are no less stringent than the applicable Medicare requirements. Additionally, the AO is responsible for enforcing compliance on the accredited MAO when deficiencies are found in those areas to which the deemed status applies. AOs who obtain deeming authority are responsible for ensuring that MAOs meet the deeming requirements established by CMS. Organizations that seek the authority to deem must meet CMS’s definition of a private, national AO, by demonstrating the following: 1. It is recognized as an accrediting body by the managed care industry and relevant national associations; 2. It has accredited and/or re-accredited MAOs in multiple states; 3. It contracts with or employs staff who are appropriately trained and have experience with monitoring managed care plans for compliance with the AOs specific accrediting standards; and 4. It contracts with or employs sufficient staff to provide accreditation services nationwide.