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
MCP’s may not delegate to a Subcontactor or Downstream Subcontractor their responsibility to ensure compliance with the MCP Contract.
MCPs must:
Ensure that subcontracted Hubs comply with requirements associated with their subcontracting type.
Demonstrate that they have robust compliance, monitoring, and oversight programs for subcontracted Hubs to ensure Medi-Cal Members can access and receive quality care.
Subcontracted Hubs that assume financial risk on behalf of the MCP are subject to a heightened level of oversight and monitoring to ensure compliance with Medi-Cal requirements, including ensuring financial viability and reporting medical loss ratios (MLRs) for subcontractor and Downstream Subcontractor delegated risk via a capitated payment arrangement.
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.
- Collect and review subcontracted Hubs’ ownership and control disclosures.
- 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 | Document in the Subcontractor Agreement or Downstream Subcontractor Agreement the Hub’s agreement to perform the administrative acticities, obligations, and reporting responsibilities. To the extent applicable, consider and flow down provisions pertaining the MCP’s MOUs with third-party entities. Monitor the Hub’s administrative performance, maintain oversight, and snsure compliance with relevant MCP Contract terms, regardless of the layers subcontracting. Meet the minimum requirements under Exhibit A, Attachment III, Section 3.1.1(B) and Exhibit J of the MCP Contract. |
| Tus Neeg Cog Lus Ua Haujlwm Ib Nrab lossis Tus Neeg Cog Lus Ua Haujlwm Ib Nrab | Document in the subcontractor Agreement or Downstream Subcontractor Agreement the Hub’s agreement to perform delegated functions, obligations, and reporting responsibilities. To the extent applicable, consider and flown down provisions pertaining the MCP’s MOUs with third-party entities. Monitor the Hub’s performance for all delegated functions, maintain oversight, and ensure compliance with relevant MCP Contract terms, regardless of the layers subcontracting. Meet minimum requirements under Exhibit A, Attachment III, Section 3.1.1(B) and Exhibit J of the MCP Contract. |
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 | MCPs must have mechanisms to ensure that claims processing is conducted timely and accurately in accordance with the MCP Contract, APL 23-020 and any superseding guidance, and applicable state and federal requirements, including a provider dispute resolution mechanism. Ultimately, responsibility falls to the MCP to ensure that the Hub is maintaining compliance with rules pertaining timely and accurate payments of claims to providers rendering services to Medi-Cal Members. MCPs can monitor compliance by requesting monthly reports of claims adjudicated by the Hub and conducting periodic audits. |
| 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
MCPs must regularly monitor all functions delegated to subcontractors, including Hubs, according to the MCP Contract, APL 23-006 or any superseding APL, and all relevant program requirements.
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.
- Train subcontractors and Network Providers on relevant provisions and avtivities outlined in the MCPs’ Memorandums of Understanding (MOUs) with Third Party Entities, as applicable.
- 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, thiab Kev Poob Nyiaj Kho Mob (MLRs).
- If the Hub provides direct care services in addition to its otehr Hub services, and is therefore also a Network Provider in addition to being a Subcontractor or Downstream Subcontractor, ensure the Hub’s Provider capacity is sufficient to serve all eligible Medi-Cal Members.
- Collect and review Subcontractors’ or Downstream Subcontractors’ ownership and control disclosures.
- 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.
- Revoke delegation or provide other corrective actions if the Subcontractor’s or Downstream Subcontractor’s performance is not satisfactory.
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
MCPs must maintain a system to evaluate and monitor financial viability of all subcontracted Hubs that accept financial riskl for the provisions of Covered Services. Subcontracted Hubs that assume financial risl must comply with MCP’s evaluation and monitoring protocols.
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)
Federal regulations require MCPs to annually calculate and report a medical loss ratio (MLR). Per Welfare and Institutions Code section 14197.2, DHCS established a minimum MLR standard of 85 percent and imposed a remittance requirement for MCPs that do not achieve this standard. Section 1915(b) California Advancing & Innovating Medi-Cal (CalAIM) Waiver Special Terms and Conditions (STCs) A11 requires DHCS to provide increased oversight of MLR reporting in the context of any Subcontractor or Downstream Subcontractor arrangements that assume risk, which may include Hubs, as applicable.
As of January 1, 2023, MCPs must impose MLR reporting requirements equivalent to the federally required standard on their applicable Subcontractors and Downstream Subcontractors that assume financial risk. In addition, as of January 1, 2025, MCPs must impose MLR remittance requirements equivalent to DHCS’ minimum standard for MCPs on those Subcontractors and Downstream Subcontractors. See APL 24-018 or any superseding APL for guidance on the MLR requirements applicable to Subcontractors and 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. | Maybe – see materiaity threshold info below. |
| 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 |
Note: The distinction between reporting and non-reporting entities outlines in Table 2 is based the capitated risk for services that an entity does not directly provide. In accordance with STC A11, and subject to consideration of a materiality threshold, as discussed below, MCPs must require Subcontractor Plans and other applicable subcontractors to satisfy MLR reporting and remittance requirements. Non-Reporting Entities are exempt from having to calculate and report MLR in accordance with STC A11. A singel entity may be both a Non-Reporting Entity in some instances (e.g., for certain services or arragaments) and an Other Applicable Subcontractor in other instances.
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.
For more information about exemptions for newly contracted entities, and other details see APL 24-018 or any superseding APL.
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
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