Module 3: Kev Saib Xyuas thiab Kev Soj Ntsuam ntawm Cov Chaw Pabcuam
Tshooj 1: Txheej Txheem Cej Luam
Module 3 piav qhia txog kev saib xyuas thiab kev soj ntsuam uas twb muaj lawm uas Medi-Cal Managed Care Plans (MCPs) yuav tsum ua raws li rau txhua tus Administrative Subcontractors, Administrative Downstream Subcontractors, Partially Delegated Subcontractors, thiab Partially Delegated Downstream Subcontractors, suav nrog Hubs.
Tom qab tshuaj xyuas Module 3, MCPs thiab Hubs yuav nkag siab zoo dua txog:
- Cov kev cai ua raws li txoj cai.
- Cov kev cai rau kev txhim kho cov ntaub ntawv thiab qhov zoo.
- Cov kev xav txog rau Cov Chaw Pabcuam uas xav tias muaj kev pheej hmoo nyiaj txiag lossis pabcuam rau cov pej xeem Medi-Cal tshwj xeeb sawv cev rau MCP.
Cov Ntsiab Lus Tseem Ceeb ntawm Module 3
Cov MCP yuav tsis muab lub luag haujlwm rau tus Subcontactor lossis Downstream SubContractor kom ua raws li Daim Ntawv Cog Lus MCP.
Cov MCP yuav tsum:
Xyuas kom meej tias cov Hubs uas tau cog lus ua haujlwm ua raws li cov kev cai cuam tshuam nrog lawv hom kev cog lus ua haujlwm.
Qhia tias lawv muaj cov kev pab cuam ua raws li txoj cai, kev saib xyuas, thiab kev saib xyuas zoo rau cov chaw cog lus ua haujlwm rau lwm tus kom ntseeg tau tias cov tswv cuab Medi-Cal tuaj yeem nkag mus tau thiab tau txais kev kho mob zoo.
Cov Chaw Pabcuam Uas Tau Cog Lus Ua Haujlwm Uas Muaj Kev Pheej Hmoo Nyiaj Txiag Sawv Cev Rau MCP raug saib xyuas thiab saib xyuas kom ua raws li cov cai ntawm Medi-Cal, suav nrog kev ua kom muaj kev vam meej nyiaj txiag thiab kev tshaj tawm cov piv txwv kev poob nyiaj kho mob (MLRs) rau tus neeg cog lus ua haujlwm thiab tus neeg cog lus ua haujlwm Downstream uas tau muab kev pheej hmoo los ntawm kev npaj them nyiaj rau tus kheej.
Saib Cov Lus Qhia rau cov npe ntawm cov lus qhia siv tau rau lub module no.
Tshooj 2: Cov Kev Cai Saib Xyuas thiab Kev Soj Ntsuam ntawm MCP rau Cov Chaw Pabcuam
Cov MCPs yuav tsum saib xyuas txhua lub Hubs uas tau cog lus ua haujlwm rau lwm tus, raws li Daim Ntawv Cog Lus MCP, APL 23-006 lossis lwm daim APL uas hloov pauv, thiab txhua yam uas yuav tsum tau ua ntawm qhov kev pab cuam. Yam tsawg kawg nkaus, MCPs yuav tsum:
- Tswj thiab muaj lub luag haujlwm saib xyuas kev ua raws li txhua cov kev cai thiab Cov Kev Pabcuam Uas Tau Them Nqi ntawm Daim Ntawv Cog Lus MCP raws li qhov siv tau, tsis hais txog pes tsawg txheej ntawm kev cog lus ua haujlwm ntxiv.
- Qhia meej txog txhua yam haujlwm, cov luag haujlwm, thiab cov luag haujlwm tshaj tawm uas tau muab faib rau, raws li siv tau.
- Cov Ntaub Ntawv Hauv Cov Ntawv Cog Lus Cog Tseg thiab Cov Ntawv Cog Lus Cog Tseg Downstream daim ntawv cog lus ntawm Hub los ua cov haujlwm, cov luag haujlwm, thiab cov luag haujlwm tshaj tawm, raws li siv tau.
- Develop and maintain DHCS-approved policies and procedures to ensure subcontracted Hubs meet required responsibilities and functions.
- Yog tias lub Hub uas tau cog lus ua haujlwm rau lwm tus kuj muab kev pabcuam saib xyuas ncaj qha thiab yog li ntawd kuj yog Tus Muab Kev Pabcuam hauv Network ntxiv rau kev ua Tus Muab Kev Pabcuam rau Lwm Tus lossis Tus Muab Kev Pabcuam rau Lwm Tus, xyuas kom meej tias Lub Hub lub peev xwm muab kev pabcuam txaus los pabcuam txhua tus Tswvcuab Medi-Cal uas tsim nyog.
- Tshaj tawm rau DHCS cov ntaub ntawv xav tau rau txhua lub Chaw Pabcuam uas tau cog lus ua haujlwm los ntawm Daim Ntawv Qhia J ntawm Daim Ntawv Cog Lus MCP, suav nrog cov npe ntawm txhua lub Chaw Pabcuam uas tau cog lus ua haujlwm, cov kev pabcuam uas tau muab, thiab lub nroog lossis cov nroog uas cov Tswv Cuab Medi-Cal tau txais kev pabcuam.
- Sau thiab tshuaj xyuas cov ntaub ntawv qhia txog kev muaj thiab kev tswj hwm ntawm cov Hubs uas tau cog lus ua haujlwm rau lwm tus.
- Xyuas kom tseeb tias txhua daim ntawv cog lus nrog cov Hubs uas tau cog lus ua haujlwm rau lwm tus muaj rau DHCS thaum thov.
Cov MCPs yuav tsum muab kev tshem tawm ntawm kev muab cov haujlwm lossis cov luag num, lossis qhia meej txog lwm yam kev kho, suav nrog kev kho kom raug thiab/lossis kev rau txim nyiaj txiag, qhov twg DHCS lossis MCP txiav txim siab tias Lub Chaw Haujlwm cog lus tsis ua haujlwm zoo nrog cov nqe lus ntawm lawv daim ntawv cog lus lossis txhua yam kev cai ntawm Medi-Cal uas tau muab rau lawv.
In addition, to the extent applicable, MCPs must consider and flow down provisions pertaining the MCPs’ Memorandums of Understanding (MOUs) with third-party entities in its contracts with subcontracted Hubs. The intent of this requirement is to ensure that all parties—including third-party entities, such as Local Health Jurisdictions, or Child Welfare Departments, are aware of what services MCPs have arranged to cover under subcontracting agreements. MCP are required to train, as applicable, Subcontractors, Downstream Subcontractors, and Network Providers on the MOU requirements and services provided by the third-party entity. This provision is intended to ensure the MCP provides its Subcontractors, Downstream Subcontractors, and Network Providers with information necessary for them to coordinate care with, and make referrals to, or receive referrals from, the third-party entity. For example, a Hub which includes ECM Providers for Children and Youth POF in its Network should be made aware of and help support relevant activities outlined in the MOU between the MCP and the Child Welfare Department to the extent it is applicable. See APL 23-029 or any superseding APL for additional detail.
Rooj 1: Cov Kev Cai Saib Xyuas thiab Ua Raws Cai ntawm MCP los ntawm Hom Kev Cog Lus Ua Haujlwm Qis
| Hom kev cog lus ua haujlwm rau lwm tus | Kev Saib Xyuas thiab Kev Ua Raws Cai ntawm MCP |
|---|---|
| Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Tom Qab | Sau daim ntawv cog lus rau tus neeg cog lus ua haujlwm lossis daim ntawv cog lus rau tus neeg cog lus ua haujlwm hauv qab ntawm Hub los ua cov haujlwm kev tswj hwm , cov luag haujlwm, thiab cov luag haujlwm tshaj tawm. Yog tias siv tau, xav txog thiab sau cov kev cai hais txog MCP cov MOUs nrog cov koom haum sab nraud. Saib xyuas kev ua haujlwm ntawm Hub, tswj kev saib xyuas, thiab xyuas kom ua raws li cov lus cog tseg ntawm MCP, tsis hais cov khaubncaws sab nraud povtseg uas cog lus rau lwm tus. Ua tau raws li qhov yuav tsum tau ua tsawg kawg nkaus raws li Daim Ntawv Qhia A, Daim Ntawv Ntxiv III, Ntu 3.1.1(B) thiab Daim Ntawv Qhia J ntawm Daim Ntawv Cog Lus MCP. |
| Tus Neeg Cog Lus Ua Haujlwm Ib Nrab lossis Tus Neeg Cog Lus Ua Haujlwm Ib Nrab | Sau daim ntawv cog lus rau tus neeg cog lus ua haujlwm lossis Daim Ntawv Cog Lus rau Tus Neeg Cog Lus Ua Haujlwm Qis dua qhov kev pom zoo ntawm Hub los ua cov haujlwm, cov luag haujlwm, thiab cov luag haujlwm tshaj tawm uas tau muab faib rau hauv Daim Ntawv Cog Lus. Yog tias siv tau, xav txog thiab sau cov kev cai hais txog MCP cov MOUs nrog cov koom haum sab nraud. Saib xyuas qhov kev ua haujlwm ntawm Hub rau txhua txoj haujlwm uas tau muab faib, tswj kev saib xyuas, thiab xyuas kom ua raws li cov lus cog tseg ntawm MCP, tsis hais cov khaubncaws sab nraud povtseg uas cog lus rau lwm tus. Ua tau raws li qhov yuav tsum tau ua tsawg kawg nkaus raws li Daim Ntawv Qhia A, Daim Ntawv Ntxiv III, Ntu 3.1.1(B) thiab Daim Ntawv Qhia J ntawm Daim Ntawv Cog Lus MCP. |
Rooj 2: Piv txwv ntawm Kev Ua Raws Cai ntawm MCPs thiab Hubs
| Piv txwv | Cov Kev Cai rau Kev Ua Raws Cai |
|---|---|
| Cov neeg sawv cev ntawm MCP thov kev txiav txim thiab kev them nyiaj rau lub hub | Cov MCPs yuav tsum muaj cov txheej txheem los xyuas kom meej tias kev ua cov ntaub ntawv thov tau ua tiav raws sijhawm thiab raug raws li Daim Ntawv Cog Lus MCP, APL 23-020 thiab txhua cov lus qhia hloov pauv, thiab cov kev cai ntawm lub xeev thiab tsoomfwv teb chaws, suav nrog cov txheej txheem daws teeb meem kev tsis sib haum xeeb ntawm cov neeg muab kev pabcuam. Thaum kawg, lub luag haujlwm poob rau MCP los xyuas kom meej tias Lub Chaw Pabcuam ua raws li cov cai hais txog kev them nyiaj raws sijhawm thiab raug rau cov neeg muab kev pabcuam rau cov Tswvcuab Medi-Cal. Cov MCPs tuaj yeem saib xyuas kev ua raws li txoj cai los ntawm kev thov cov ntawv qhia txhua hli ntawm cov lus thov uas tau txiav txim los ntawm Hub thiab ua kev tshuaj xyuas tsis tu ncua. |
| MCP muab kev sau npe thiab daim ntawv pov thawj rau tus kws kho mob rau Hub | MCPs must ensure Hubs set and adhere to enrollment and credentialing policies in accordance with MCP Contract, APL 19-004 and any superseding guiance, and the Medi-Cal Provider Manual. The MCP is responsible for ensuring that the Hub is maintaining compliance with enrollment and credentialing requirements. MCPs can monitor compliance by requesting reports of the providers that the Hub enrolls/credentials and conducting periodic audits. |
Daim Ntawv Teev Cov Kev Cai Ua Raws Cai ntawm MCP-Hub
Cov MCPs yuav tsum saib xyuas txhua txoj haujlwm uas tau muab rau cov neeg cog lus ua haujlwm, suav nrog Hubs, raws li Daim Ntawv Cog Lus MCP, APL 23-006 lossis lwm yam APL hloov pauv, thiab txhua yam kev xav tau ntawm qhov kev pab cuam.
Yam tsawg kawg nkaus, MCPs yuav tsum:
- Saib xyuas kev ua raws li Daim Ntawv Cog Lus MCP.
- Muab cov kev cai meej meej rau hauv daim ntawv cog lus ntawm tus neeg cog lus uas piav qhia txog txhua yam haujlwm, cov luag haujlwm, thiab cov luag haujlwm tshaj tawm cuam tshuam.
- Tsim thiab tswj cov cai thiab cov txheej txheem uas DHCS tau pom zoo kom ntseeg tau tias cov neeg cog lus ua tiav cov luag haujlwm thiab cov haujlwm uas yuav tsum tau ua.
- Tshaj tawm rau DHCS cov ntaub ntawv xav tau rau txhua lub Chaw Pabcuam uas tau cog lus ua haujlwm los ntawm Daim Ntawv Qhia J ntawm Daim Ntawv Cog Lus MCP, suav nrog cov npe ntawm txhua lub Chaw Pabcuam uas tau cog lus ua haujlwm, cov kev pabcuam uas tau muab, thiab lub nroog lossis cov nroog uas cov Tswv Cuab Medi-Cal tau txais kev pabcuam.
- Qhia cov neeg cog lus thiab cov neeg muab kev pabcuam hauv network txog cov kev cai thiab cov haujlwm uas tau teev tseg hauv MCPs cov ntawv cog lus nkag siab (MOUs) nrog cov chaw thib peb, raws li siv tau.
- Yog tias Lub Chaw Pabcuam lees txais kev pheej hmoo sawv cev rau MCP, xyuas kom ua raws li cov kev cai ntawm kev muaj peev xwm nyiaj txiag, Kev Ntsuas Cov Kev Xav Tau ntawm Cov Neeg (PNA), Kev Txaus ntawm Lub Koom Haum Subcontractor Network, thiab Kev Poob Nyiaj Kho Mob (MLRs).
- Yog tias Lub Chaw Muab Kev Pabcuam Ncaj Qha ntxiv rau nws cov kev pabcuam otehr Hub, thiab yog li ntawd kuj yog Tus Muab Kev Pabcuam Network ntxiv rau kev ua Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Downstream, xyuas kom meej tias Lub Chaw Muab Kev Pabcuam muaj peev xwm txaus los pabcuam txhua tus Tswvcuab Medi-Cal uas tsim nyog.
- Sau thiab tshuaj xyuas cov Subcontractors lossis Downstream Subcontractors cov kev tshaj tawm txog kev muaj thiab kev tswj hwm.
- Xyuas kom tseeb tias txhua daim ntawv cog lus nrog Cov Neeg Cog Lus Ua Haujlwm thiab Cov Ntawv Cog Lus Ua Haujlwm Hauv Qab muaj rau DHCS thaum thov.
- Tshem tawm txoj cai los yog muab lwm yam kev kho yog tias Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Hauv Qab tsis ua haujlwm zoo.
Tshooj 3: Cov Kev Cai Txhim Kho Cov Ntaub Ntawv thiab Kev Zoo
Cov MCPs uas cog lus nrog Hubs rau kev tswj hwm thiab/lossis kev xa cov txiaj ntsig Medi-Cal yuav tsum ua raws li cov ntaub ntawv tshaj tawm thiab Kev Txhim Kho Zoo (QI) cov kev cai teev tseg hauv Daim Ntawv Cog Lus MCP thiab APL 23-006 (lossis ib qho APL hloov pauv). Tej zaum yuav muaj lwm cov kev cai ntxiv txog kev tshaj tawm cov ntaub ntawv tshwj xeeb ntawm qhov kev pab cuam thiab QI.
Cov Kev Cai Qhia Txog Cov Ntaub Ntawv
Cov MCPs yuav tsum muaj cov txheej txheem los saib xyuas qhov kev ua raws li cov ntaub ntawv tshaj tawm ntawm Hub uas tau cog lus ua haujlwm, suav nrog cov txheej txheem los xyuas kom meej tias cov ntaub ntawv tiav, raug, tsim nyog thiab raws sijhawm. Qhov no suav nrog, tab sis tsis txwv rau cov ntaub ntawv uas tuaj yeem txhawb nqa MCP kev tshaj tawm ntawm Encounter Data, cov ntaub ntawv txhua hli 274 Provider Network, Managed Care Program Data (MCPD), cov ntaub ntawv tshaj tawm los ntawm cov qauv peb lub hlis, kev tshaj tawm kev txheeb xyuas kev mus ntsib hauv hluav taws xob, thiab lwm yam kev thov cov ntaub ntawv ad hoc uas DHCS xav tau, mus rau qhov uas nws cuam tshuam rau subcontracted Hub.
Cov Kev Cai Txhim Kho Zoo
Cov MCPs muaj lub luag haujlwm rau txhua yam haujlwm QI thiab Kev Ncaj Ncees ntawm Kev Noj Qab Haus Huv uas tau muab rau cov chaw cog lus raws li tau teev tseg hauv lawv Cov Ntawv Cog Lus Cog Lus lossis Cov Ntawv Cog Lus Cog Lus Downstream, raws li siv tau. Cov MCPs yuav tsum saib xyuas thiab saib xyuas kom txaus kom ntseeg tau tias ua raws li txhua yam haujlwm QI uas tau muab faib, suav nrog, tsawg kawg:
- Tshuaj xyuas lub peev xwm ntawm Subcontracted Hub los ua cov haujlwm uas tau muab faib rau lwm tus, suav nrog kev txiav txim siab thawj zaug tias Subcontracted Hub muaj peev xwm tswj hwm, kev paub dhau los, thiab cov peev txheej nyiaj txiag los ua kom tiav cov luag haujlwm cog lus.
- Xyuas kom tseeb tias cov Chaw Pabcuam uas tau cog lus ua haujlwm ua ke ua tau raws li cov cai ntawm QI thiab Kev Ncaj Ncees ntawm Kev Noj Qab Haus Huv uas tau teev tseg hauv Daim Ntawv Cog Lus MCP.
- Xyuas kom meej tias MCP txuas ntxiv saib xyuas, ntsuam xyuas, thiab pom zoo rau nws cov haujlwm uas tau muab rau cov chaw cog lus hauv qab, suav nrog kev ua kom cov ntaub ntawv los ntawm cov txheej txheem saib xyuas thiab ntsuam xyuas no muaj tsawg kawg yog txhua xyoo lossis thaum DHCS thov.
Cov MCPs yuav tsum xyuas kom meej tias lub Hub uas tau cog lus ua haujlwm rau lwm tus ua raws li nws cov Cai thiab Cov Txheej Txheem Kev Txhim Kho Zoo thiab Kev Hloov Pauv Kev Noj Qab Haus Huv (QIHETP).
Cov Cuab Yeej Txhim Kho Zoo ntawm MCP-Hub
Cov MCPs muaj lub luag haujlwm rau txhua qhov kev txhim kho zoo (QI) thiab kev ua haujlwm ntawm Kev Ncaj Ncees Kev Noj Qab Haus Huv uas tau muab rau Cov Neeg Cog Lus thiab Cov Neeg Cog Lus Hauv Qab raws li tau teev tseg hauv lawv Cov Lus Cog Tseg thiab Cov Lus Cog Tseg Hauv Qab, raws li siv tau. Cov MCPs yuav tsum saib xyuas thiab saib xyuas kom txaus kom ntseeg tau tias ua raws li txhua yam haujlwm QI uas tau muab faib rau. Cov MCPs uas tswj hwm daim ntawv pov thawj kev npaj kho mob NCQA yuav tsum xyuas kom ua raws li txhua tus qauv thiab cov lus qhia ntawm NCQA txog kev sib raug zoo ntawm cov neeg cog lus.
Yam tsawg kawg nkaus, MCPs yuav tsum:
- Ua ntej muab ib txoj haujlwm rau Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Tom Qab, soj ntsuam tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Tom Qab lub peev xwm los ua cov haujlwm uas tau muab faib, suav nrog kev txiav txim siab thawj zaug tias Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Tom Qab muaj peev xwm tswj hwm, kev paub dhau los, thiab cov peev txheej nyiaj txiag los ua tiav cov luag haujlwm cog lus.
- Xyuas kom meej tias Cov Neeg Cog Lus Ua Haujlwm thiab Cov Neeg Cog Lus Ua Haujlwm Ua Haujlwm Ua Ntej ua tau raws li QI thiab Kev Pabcuam Hloov Kho Kev Ncaj Ncees Hauv Kev Noj Qab Haus Huv (QIHETP) cov cai uas tau teev tseg hauv Daim Ntawv Cog Lus MCP, kom txog thaum siv tau.
- Xyuas kom meej tias MCP txuas ntxiv saib xyuas, ntsuam xyuas, thiab pom zoo rau nws cov haujlwm uas tau muab rau Cov Neeg Cog Lus thiab Cov Neeg Cog Lus Hauv Qab, suav nrog kev ua kom cov ntaub ntawv los ntawm cov txheej txheem saib xyuas thiab ntsuam xyuas no muaj tsawg kawg yog txhua xyoo lossis thaum DHCS thov.
Tshooj 4: Kev Xav Ntxiv rau Cov Chaw Pabcuam uas Muaj Kev Pheej Hmoo Nyiaj Txiag lossis Them Rau Cov Neeg Tswv Cuab Medi-Cal Tshwj Xeeb
Ib lub Hub lees txais kev pheej hmoo nyiaj txiag rau MCP los ntawm kev sib koom kev pheej hmoo thiab kev npaj hloov kev pheej hmoo. Cov Chaw Pabcuam uas tau cog lus ua haujlwm rau lwm tus uas muaj kev pheej hmoo nyiaj txiag sawv cev rau MCP yuav raug saib xyuas thiab saib xyuas ntau dua kom ntseeg tau tias ua raws li cov cai ntawm Medi-Cal. Qhov no suav nrog cov kev cai ntsig txog:
- Kev Muaj Peev Xwm Nyiaj Txiag
- Kev Ntsuam Xyuas Cov Kev Xav Tau ntawm Cov Neeg
- Cov Piv Txwv Kev Poob Nyiaj Kho Mob (MLRs)
Cov Kev Cai Nyiaj Txiag Muaj Peev Xwm
Cov MCPs yuav tsum tswj hwm ib lub txheej txheem los ntsuam xyuas thiab saib xyuas kev ua tau nyiaj txiag ntawm txhua lub Hubs uas tau cog lus ua haujlwm uas lees txais kev pheej hmoo nyiaj txiag rau cov kev pabcuam ntawm Cov Kev Pabcuam Uas Tau Them. Cov Chaw Pabcuam uas tau cog lus ua haujlwm rau lwm tus uas xav tias muaj kev pheej hmoo nyiaj txiag yuav tsum ua raws li MCP cov txheej txheem ntsuam xyuas thiab saib xyuas.
Cov Kev Cai Ntsuas Cov Kev Xav Tau ntawm Cov Neeg
Qhov kev pab cuam Kev Tswj Xyuas Kev Noj Qab Haus Huv ntawm Cov Neeg (PHM) ua kom txhua tus Tswv Cuab Medi-Cal muaj kev nkag mus rau cov kev pabcuam dav dav raws li lawv cov kev xav tau thoob plaws hauv kev saib xyuas. Nyob rau hauv qhov kev pab cuam PHM, MCPs, lawv cov tes hauj lwm, thiab lawv cov neeg koom tes, suav nrog cov neeg cog lus ua haujlwm, yog lub luag haujlwm rau cov kev xav tau ntawm Medi-Cal Cov Tswv Cuab hauv cov zej zog uas lawv pabcuam raws li cov qauv thiab cov kev cia siab. Qhov no suav nrog kev muab cov ntaub ntawv nkag mus rau Medi-Cal cov neeg koom nrog:
- Cov keeb kwm kev noj qab haus huv ntawm cov tswv cuab Medi-Cal, cov kev xav tau, thiab cov kev pheej hmoo, thiab lwm cov ntaub ntawv ntawm qhov kev pab cuam los txhawb kev faib ua pawg ntawm cov kev pheej hmoo; kev ntsuam xyuas thiab cov txheej txheem tshuaj xyuas.
- Kev txhawb nqa kho mob, kev coj cwj pwm, thiab kev sib raug zoo.
- Kev tshuaj xyuas thiab cov txheej txheem tshaj tawm.
The Population Needs Assessment (PNA) helps MCPs identify Medi-Cal Member and community needs and health disparities. MCPs meet the PNA requirement through meaningful participation in the Community Health Assessments (CHAs) and Community Health Improvement Plans (CHIPs) conducted by Local Health Jurisdictions (LHJs). MCP’s must ensure that any Medi-Cal Member populations covered by a Subcontractor or Downstream Subcontractor, including Hubs, are included in the PNA process. Subcontractors do not participate in the PNA separately; the MCP is responsible for including these populations in the PNA process. See the PHM Policy Guide and MCP Contract for additonal information.
Cov Piv Txwv Kev Poob Nyiaj Kho Mob (MLRs)
Cov cai lij choj hauv tebchaws xav kom MCPs xam thiab tshaj tawm txhua xyoo txog qhov piv ntawm kev poob nyiaj kho mob (MLR). Raws li Tshooj Cai Kev Noj Qab Haus Huv thiab Cov Tsev Kawm Ntawv 14197.2, DHCS tau tsim tsa tus qauv MLR tsawg kawg nkaus ntawm 85 feem pua thiab tau tsim kom muaj kev xa nyiaj rov qab rau MCPs uas tsis ua tiav tus qauv no. Tshooj 1915(b) California Advancing & Innovating Medi-Cal (CalAIM) Waiver Cov Lus Cog Tseg Tshwj Xeeb thiab Cov Cai (STCs) A11 yuav tsum tau DHCS kom muab kev saib xyuas ntxiv ntawm MLR kev tshaj tawm hauv cov ntsiab lus ntawm txhua qhov kev npaj Subcontractor lossis Downstream Subcontractor uas muaj kev pheej hmoo, uas yuav suav nrog Hubs, raws li siv tau.
Txij li Lub Ib Hlis 1, 2023, MCPs yuav tsum tsim cov kev cai tshaj tawm MLR sib npaug rau tus qauv uas tsoomfwv xav tau rau lawv cov Neeg Cog Lus thiab Cov Neeg Cog Lus Hauv Qab uas muaj kev pheej hmoo nyiaj txiag. Ntxiv mus, txij li Lub Ib Hlis 1, 2025, MCPs yuav tsum tsim cov kev cai xa nyiaj MLR sib npaug rau DHCS tus qauv tsawg kawg nkaus rau MCPs ntawm cov Subcontractors thiab Downstream Subcontractors. Saib APL 24-018 lossis lwm yam APL hloov pauv rau cov lus qhia txog MLR cov kev cai siv rau Subcontractors thiab Downstream Subcontractors.
Rooj 3: Cov Chaw Ua Haujlwm Uas Yuav Tsum Tau Ua Raws Li Cov Kev Cai Qhia Txog MLR Thiab Kev Xa Nyiaj Rov Qab
| Hom chaw | Txhais | Yuav ua li cas rau MLR? |
|---|---|---|
| Cov Phiaj Xwm Rau Cov Neeg Cog Lus Ua Haujlwm | Cov phiaj xwm uas lees txais tag nrho lossis ib feem ntawm kev pheej hmoo los ntawm MCP, lossis nws Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Tom Qab, hauv thaj chaw muab kev pabcuam. | Maybe – see materiality threshhold info belo |
| Lwm Cov Neeg Cog Lus Ua Haujlwm lossis Cov Neeg Cog Lus Ua Haujlwm Hauv Qab | Cov Neeg Cog Lus Ua Haujlwm lossis Cov Neeg Cog Lus Ua Haujlwm Hauv Qab, tshwj tsis yog Cov Neeg Cog Lus Ua Haujlwm lossis Cov Phiaj Xwm Ua Haujlwm Hauv Qab, uas lees txais kev pheej hmoo thiab tau txais kev them nyiaj los ntawm MCP, lossis nws Cov Neeg Cog Lus Ua Haujlwm lossis Cov Neeg Cog Lus Ua Haujlwm Hauv Qab, rau cov kev pabcuam uas muab dhau ntawm lawv tus kheej lub koom haum (piv txwv li, cov kev pabcuam uas lawv tsis xa ncaj qha rau Cov Tswv Cuab Medi-Cal). Qhov no yuav suav nrog IPAs, cov pab pawg kho mob, cov kab ke hauv tsev kho mob, lossis lwm cov chaw. | Tej zaum - saib cov ntaub ntawv qhia txog qhov ntsuas khoom siv hauv qab no. |
| Cov Chaw Tsis Tshaj Tawm | Cov Chaw Muab Kev Pabcuam Hauv Network, cov Neeg Cog Lus Ua Haujlwm lossis cov Neeg Cog Lus Ua Haujlwm hauv qab, thiab cov Neeg Cog Lus Ua Haujlwm lossis cov Neeg Cog Lus hauv qab uas tsis siv tau uas tsis lees txais kev pheej hmoo lossis lees txais kev pheej hmoo tsuas yog rau cov kev pabcuam uas muab hauv lawv lub koom haum xwb. | No – exempt |
Lus Cim: Qhov sib txawv ntawm cov chaw tshaj tawm thiab cov chaw tsis tshaj tawm uas tau teev tseg hauv Rooj 2 yog raws li qhov kev pheej hmoo rau cov kev pabcuam uas ib lub chaw tsis muab ncaj qha. Raws li STC A11, thiab raws li kev txiav txim siab ntawm qhov tseem ceeb, raws li tau tham hauv qab no, MCPs yuav tsum xav kom Subcontractor Plans thiab lwm cov subcontractors siv tau kom ua tau raws li MLR kev tshaj tawm thiab kev xa nyiaj rov qab. Cov Chaw Tsis Tshaj Tawm raug zam tsis tas yuav suav thiab tshaj tawm MLR raws li STC A11. Ib lub koom haum ib leeg yuav yog ob qho tib si Lub Koom Haum Tsis Tshaj Tawm hauv qee kis (piv txwv li, rau qee cov kev pabcuam lossis kev sib cog lus) thiab Lwm Tus Neeg Cog Lus Ua Haujlwm Hauv Lwm Qhov Xwm Txheej.
Qhov Tseem Ceeb ntawm Cov Khoom Siv
Cov MCPs yuav tsum siv qhov materiality threshold uas DHCS tau tsim los txiav txim seb lub subcontracted lossis downstream subcontracyed Hub puas raug rau STC A11 reporting thiab returning requirements.
Rau xyoo CY 2023 MLR tshaj tawm, thiab txog thaum DHCS hloov kho, cov chaw cog lus uas tau txais ib qho nyiaj hauv Medi-Cal Capitation txhua xyoo, los ntawm ib lub koom haum sab saud, ua kev them nyiaj rau cov kev pabcuam uas tau muab hauv ib lub nroog lossis thaj chaw ntsuas, uas lawv xav tias muaj kev pheej hmoo thiab tsis muab ncaj qha yuav raug rau cov kev cai tshaj tawm MLR. Cov Chaw Pabcuam uas tau cog lus ua haujlwm rau lwm tus uas poob qis dua tus nqi txhua xyoo yuav tsis raug tshaj tawm rau xyoo tshaj tawm MLR uas tau muab, tsuas yog raws li DHCS xav tau ntawm ib kis zuj zus. Rau xyoo CY 2023 MLR tshaj tawm, thiab txog thaum DHCS hloov kho, qhov tseem ceeb ntawm $ 30,000,000 hauv Medi-Cal tus nqi txhua xyoo, los ntawm ib lub koom haum sab saud, ua kev them nyiaj rau cov kev pabcuam uas tau muab hauv ib lub nroog lossis thaj chaw ntsuas, uas Tus Neeg Cog Lus Ua Haujlwm lossis Tus Neeg Cog Lus Ua Haujlwm Sab Hauv qab lees txais kev pheej hmoo thiab tsis muab ncaj qha.
Yog xav paub ntxiv txog kev zam rau cov chaw tshiab cog lus, thiab lwm yam ntsiab lus saib APL 24-018 lossis lwm yam APL hloov chaw.
Tshooj 5: Cov Lus Qhia Txog Lub Luag Haujlwm Saib Xyuas MCP
Rau txhua lub Hubs uas tau cog lus ua haujlwm rau lwm tus:
- Kev saib xyuas thiab kev soj ntsuam
- Ua raws
- Cov ntaub ntawv thiab kev tshaj tawm
- Kev Txhim Kho Zoo
Rau cov chaw cog lus ua haujlwm uas them rau cov pej xeem Medi-Cal Member:
- Kev muaj peev xwm nyiaj txiag
- Suav nrog rau hauv PNA
Rau cov Hubs uas tau cog lus ua haujlwm rau lwm tus uas muaj kev pheej hmoo:
- Xyuas seb MLR puas siv tau
Cov Lus Qhia Tseem Ceeb
Daim Ntawv Cog Lus Xyoo 2024 MCP Boilderplate
Tswj Xyuas Kev Kho Mob Txhua Tsab Ntawv Qhia Txog Kev Npaj (APLs)
APL 23-001: Cov Kev Cai Rau Daim Ntawv Pov Thawj Network
APL 23-006: Kev Pom Zoo rau Kev Tswj Xyuas thiab Kev Cog Lus Hauv Network
APL 23-020: Cov Kev Cai rau Kev Them Nyiaj Raws Sijhawm ntawm Cov Lus Thov
APL 23-029: Daim Ntawv Cog Lus Nkag Siab Cov Kev Cai rau Cov Phiaj Xwm Kev Kho Mob thiab Cov Chaw Sab Nraud
APL 20-017: Cov Kev Cai rau Kev Tshaj Tawm Cov Ntaub Ntawv Kev Pabcuam Kev Kho Mob
APL 19-001: Cov Lus Qhia Txog Kev Npaj Kho Mob Medi-Cal Managed Care Health Plan txog Cov Xwm Txheej ntawm Network Provider
APL 24-018: Cov Kev Cai Rau Kev Poob Nyiaj Kho Mob Rau Cov Neeg Cog Lus Ua Haujlwm thiab Cov Neeg Cog Lus Ua Haujlwm Tom Qab
PHM Txoj Cai Qhia
ECM Txoj Cai Qhia
Zej Zog Txhawb Nqa Txoj Cai Phau Ntawv Qhia Volume 1
Zej Zog Txhawb Nqa Txoj Cai Qhia Phau Ntawv Teev Npe 2