模块 3：枢纽的监督和监测
第 1 部分：概述
模块 3 描述了 Medi-Cal 托管护理计划 (MCP) 必须遵守的对所有行政分包商、行政下游分包商、部分授权分包商和部分授权下游分包商（包括 Hubs）的现有监督和监控要求。
学习模块 3 后，多边协商程序和枢纽将更好地理解以下内容：
- 合规要求。
- 数据和质量改进要求。
- 中心承担财务风险或代表 MCP 为特定 Medi-Cal 会员提供服务的考虑因素。
模块 3 主要收获
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.
有关本模块的适用指南清单，请参见参考资料。
第 2 部分：MCP 对枢纽的监督和监测要求
多方合作伙伴计划必须根据多方合作伙伴计划合同、 APL 23-006 或任何替代 APL 以及所有相关计划要求，定期对所有分包中心进行监控。多边协商程序至少必须
- 维护并负责监督 MCP 合同中所有适用条款和承保服务的合规性，无论分包层级有多少。
- 具体说明所有授权活动、义务和相关报告责任（如适用）。
- 在《分包商协议》和《下游分包商协议》中记录枢纽公司同意履行授权活动、义务和报告责任（如适用）。
- Develop and maintain DHCS-approved policies and procedures to ensure subcontracted Hubs meet required responsibilities and functions.
- 如果分包枢纽中心也提供直接护理服务，因此除了是分包商或下游分包商外还是网络提供商，则应确保枢纽中心的提供商能力足以为所有符合条件的 Medi-Cal 会员提供服务。
- 通过 MCP 合同附件 J 向 DHCS 报告所有分包中心的必要信息，包括所有分包中心的名称、提供的服务以及 Medi-Cal 会员所服务的一个或多个县。
- Collect and review subcontracted Hubs’ ownership and control disclosures.
- 确保与分包中心签订的所有合同可应 DHCS 的要求提供。
当 DHCS 或 MCP 认定签约枢纽没有令人满意地履行合同条款或任何 Medi-Cal 委托给他们的要求时，MCP 必须规定撤销活动或义务的委托，或规定其他补救措施，包括纠正措施和/或经济制裁。
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.
表 1：按分包类型分列的 MCP 监督和合规要求
| 分包类型 | 多边协商程序的监督和合规要求 |
|---|---|
| 行政分包商或下游行政分包商 | 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. |
| 部分委托分包商或下游部分委托分包商 | 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. |
表 2：多边协商中心与枢纽之间的合规活动示例
| 示例 | 合规要求 |
|---|---|
| MCP 将条款裁定和付款委托给一个中心 | 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 将提供方注册和资格认证委托给中心 | 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. |
MCP-Hub 合规要求核对表
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.
多边协商程序至少必须
- 监督 MCP 合同的履行情况。
- 在分包商协议中列入明确条款，概述所有委托活动、义务和相关报告责任。
- 制定并维护 DHCS 批准的政策和程序，确保分包商履行规定的责任和职能。
- 通过 MCP 合同附件 J 向 DHCS 报告所有分包中心的必要信息，包括所有分包中心的名称、提供的服务以及 Medi-Cal 会员所服务的一个或多个县。
- Train subcontractors and Network Providers on relevant provisions and avtivities outlined in the MCPs’ Memorandums of Understanding (MOUs) with Third Party Entities, as applicable.
- 如果中心代表 MCP 接受风险，则应确保符合财务可行性、人口需求评估 (PNA)、分包商网络充足性和医疗损失率 (MLR) 要求。
- 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.
- 确保与分包商签订的所有合同和下游分包商协议可供 DHCS 索要。
- Revoke delegation or provide other corrective actions if the Subcontractor’s or Downstream Subcontractor’s performance is not satisfactory.
第 3 部分：数据和质量改进要求
与 Hubs 签订合同管理和/或提供 Medi-Cal 福利的 MCP 必须遵守 MCP 合同和APL 23-006（或任何后续 APL）中规定的数据报告和质量改进 (QI) 要求。其他针对具体计划的数据报告和 QI 要求也可能适用。
数据报告要求
MCP 必须建立机制来监督分包 Hub 对数据报告的遵守情况，包括验证数据是否完整、准确、合理和及时的系统。这可能包括但不限于能够支持 MCP 报告 "会诊数据 "的数据、每月 274 提供者网络数据文件、管理性医疗计划数据 (MCPD)、通过季度模板报告的数据、电子就诊验证报告，以及 DHCS 要求的任何其他特别数据要求，只要与分包枢纽相关即可。
质量改进要求
MCP 对其分包商协议或下游分包商协议（如适用）中规定的委托给分包中心的任何 QI 和健康公平职能负责。医疗控制点必须保持足够的监督和监测，以确保遵守所有委托的质量改进活动，至少包括
- 评估分包枢纽中心执行委托活动的能力，包括初步确定分包枢纽中心是否具备履行合同义务所需的行政能力、经验和预算资源。
- 确保分包中心符合 MCP 合同中规定的 QI 和健康公平要求。
- 确保 MCP 不断监督、评估和批准其对分包中心的委托职能，包括至少每年一次或在 DHCS 要求时提供监督和评估过程的结果。
MCP 还必须确保分包 Hub 遵守其 "质量改进和健康公平转型计划 "政策和程序 (QIHETP)。
MCP-Hub 质量改进工具
MCP 对其分包商协议和下游分包商协议（如适用）中规定的委托给分包商和下游分包商的任何质量改进 (QI) 和健康公平职能负责。医疗控制点必须保持足够的监督和监测，以确保遵守所有委托的质量改进活动。获得 NCQA 医疗计划认证的 MCP 必须确保遵守 NCQA 有关分包关系的所有适用标准和指南。
多边协商程序至少必须
- 在向分包商或下游分包商委派任何职能之前，应评估分包商或下游分包商执行委派活动的能力，包括初步确定分包商或下游分包商是否具备履行合同义务所需的管理能力、经验和预算资源。
- 确保分包商和下游分包商在适用范围内满足 MCP 合同中规定的 QI 和健康公平转型计划 (QIHETP) 要求。
- 确保 MCP 对其委托给分包商和下游分包商的职能进行持续监控、评估和批准，包括至少每年一次或在 DHCS 提出要求时提供监控和评估过程的结果。
第 4 部分：对承担财务风险或覆盖特定加州医疗保险成员人群的中心的额外考虑
枢纽中心通过风险分担和风险转移安排承担多边协商程序的财务风险。 代表 MCP 承担财务风险的分包中心须接受更高级别的监督和监测，以确保符合 Medi-Cal 的要求。这包括以下方面的要求
- 财务可行性
- 人口需求评估
- 医疗损失率 (MLR)
财务可行性要求
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.
人口需求评估要求
人口健康管理 (PHM) 计划确保所有 Medi-Cal 会员都能根据他们在整个护理过程中的需求获得适当的综合服务。在 PHM 计划下，MCP、其网络及其合作伙伴（包括适用的分包商）负责根据标准化框架和一系列期望满足其所服务社区内 Medi-Cal 会员的需求。这包括向 Medi-Cal 的利益相关者提供以下方面的数据：
- Medi-Cal 会员的健康史、需求和风险，以及其他支持风险分层的计划信息；评估和筛查程序。
- 医疗、行为和社会支持。
- 分析和报告流程。
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.
医疗损失率 (MLR)
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.
表 3：受 MLR 报告和汇款要求约束的实体
| 实体类型 | 定义 | 是否受 MLR 限制？ |
|---|---|---|
| 分包商计划 | 在某一服务区域内，承担多边协商程序或其分包商或下游分包商全部或部分委托风险的计划。 | Maybe – see materiality threshhold info belo |
| 其他适用分包商或下游分包商 | 分包商或下游分包商，但分包商或下游分包商计划除外，这些计划承担风险并从 MCP 或其分包商或下游分包商处获得付款，以提供其实体以外的服务（即他们不直接提供给 Medi-Cal 会员的服务）。这可能包括 IPA、医疗集团、医院系统或其他实体。 | Maybe – see materiaity threshold info below. |
| 非报告实体 | 网络提供商、纯粹的行政分包商或下游行政分包商，以及不承担风险或仅对其自身实体内提供的 服务承担风险的非适用分包商或下游分包商。 | 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.
重要性阈值
MCP 必须使用 DHCS 确定的重要性阈值，以确定分包或下游分包枢纽是否须遵守 STC A11 报告和汇款要求。
在 2023 CY MLR 报告年度，在 DHCS 修改之前，适用的分包枢纽每年从单一上游实体收到一定金额的 Medi-Cal 人头费，作为在单一县或评级地区提供服务的付款，他们承担风险，不直接提供服务，将受 MLR 报告要求的约束。低于年度阈值金额的分包中心无需在特定 MLR 报告年度进行报告，除非 DHCS 逐案要求。对于 CY 2023 MLR 报告年度，在 DHCS 修改之前，Medi-Cal 按人头付费的实质性阈值为每年 30,000,000 美元，来自单一上游实体，作为在单一县或评级区域提供服务的付款，适用的分包商或下游分包商为其承担风险且不直接提供服务。
For more information about exemptions for newly contracted entities, and other details see APL 24-018 or any superseding APL.
第 5 部分：MCP 监督职责概述
适用于所有分包枢纽：
- 监督和监测
- 遵守
- 数据和报告
- 质量改进
对于覆盖 Medi-Cal 成员人群的分包中心：
- 财务可行性
- 纳入 PNA
对于承担风险的分包枢纽：
- 检查是否适用 MLR
主要参考资料
2024 年 MCP 模板合同
管理护理所有计划信函 (APL)
APL 23-001：网络认证要求
APL 23-006：授权和分包商网络认证
APL 23-020：及时支付索赔的要求
APL 23-029：医疗管理计划和第三方实体的谅解备忘录要求
APL 20-017：管理式医疗计划数据报告要求
APL 19-001：加州医疗保险管理式保健计划关于网络提供方地位的指导意见
APL 24-018：分包商和下游分包商的医疗损失率要求
PHM 政策指南
ECM政策指南
社区支持政策指南第一卷
社区支持政策指南第二卷