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Medicare Advantage Deeming

Health Plans that earn NCQA Medicare Advantage deeming are deemed for Medicare requirements for Special Needs Plan Model of Care requirements.

What is NCQA Medicare Advantage Deeming?

CMS rules allow for deeming of some of the requirements it audits for by a CMS-approved private, national accreditation organization. CMS approved NCQA for deeming of Special Needs Plans (SNPs) Model of Care (MOC) requirements. NCQA evaluates plans against a set of standards for MOCs. Organizations that meet NCQA SNP deeming module requirements are deemed for Medicare requirements for SNP MOC.

How Does Medicare Advantage Deeming Help Our Organization?

For organizations that earned deemed status:

  • If a plan gets audited by CMS, then CMS can bypass auditing the Model of Care requirements, as the plan has already demonstrated meeting the requirements through NCQA.
  • Plans know their model of care is set up to help meet the unique needs of this high need, high cost population.
  • Plans earn the NCQA seal, which they can display in marketing and advertising materials as a quality and trust marker.

What Are The Requirements for NCQA MA Deeming?

The MA Deeming Module evaluates 11 areas:

Practitioner Participation- The organization has established policies and procedures and provided required notices relating to practitioner participation.

Quality Improvement Program- The organization measures and reports performance to CMS.

Ensuring Appropriate Utilization- The organization monitors and analyzes relevant data and acts to correct patterns of potential or actual inappropriate underutilization or overutilization.

Program Structure- The organization has the QI infrastructure necessary to improve the quality and safety of clinical care and services it provides to its members.

Program Operations- The organization’s QI Committee and practitioners develop, implement and oversee the QI program.

Continuity and Coordination of Medical Care- The organization uses information at its disposal to facility continuity and coordination of medical care across its delivery system.

Continuity and Coordination Between Medical Care and Behavioral Healthcare- The organization collaborates with behavioral healthcare practitioners and uses information at its disposal to coordinate medical care and behavioral healthcare.

Utilization Program Structure- The organization has a well-structured UM program and makes utilization decisions affecting the health care of members in a fair, impartial and consistent manner.

Clinical Criteria for UM Decisions- The organization applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services.

Assessing and Coordinating Care (SNP Specific)- The organization assesses and coordinates care by administering a comprehensive assessment, developing individual care plans and developing appropriate interdisciplinary care teams for members.

Plan Performance Monitoring and Evaluation of the MOC (SNP Specific)- The organization monitors and evaluates their MOC by collecting data, evaluating performance and taking action on identified opportunities.

Find the standards for NCQA Medicare Advantage Deeming in the Standards and Guidelines document.

Where Can I Find the Standards and Guidelines?

Find the Standards and Guidelines document, the survey tool and application in the NCQA Store.

What Organizations Are Eligible for Medicare Advantage Deeming?

NCQA Medicare Advantage Deeming is only available to SNP plans. Organizations earn deemed status at the H contract number level.

Do We Need To Be Accredited to Earn NCQA Medicare Advantage Deeming?

No. You are not required to already be accredited/certified to earn NCQA Medicare Advantage Deeming.

How Much Does Medicare Advantage Deeming Cost?

The price is $10,000 per H number seeking deeming.

How Long Will It Take To Earn Medicare Advantage Deeming?

It depends on how many program requirements you have already implemented. After you submit the survey, it takes approximately 60–90 days to receive a decision from NCQA. NCQA recommends that you perform a gap analysis and begin implementing changes in your organization from 9–12 months before the date when you want to earn distinction.

How Do We Start?

If your organization is not currently accredited and is interested in learning more, contact NCQA.

If you already are accredited and want to talk to someone about your current status or about renewing, submit a question through My NCQA.

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