單元 3：樞紐的監督和監測
第 1 節：概述
模組 3 描述 Medi-Cal 管理性護理計劃 (MCP) 對所有行政分包商、行政下游分包商、部分委託分包商和部分委託下游分包商（包括 Hubs）必須遵守的現有監督和監控規定。
閱讀單元 3 之後，MCP 和 Hub 會對下列事項有更深入的了解：
- 合規要求。
- 資料和品質改善要求。
- Hubs 承擔財務風險或代表 MCP 服務特定 Medi-Cal 會員群組的考慮因素。
單元 3 主要心得
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.
請參閱「參考資料」，以取得本單元的適用指引清單。
第 2 節：MCP 對樞紐的監督和監測要求
MCP 必須根據 MCP 合約、 APL 23-006 或任何替代 APL 以及所有相關計劃要求，定期監控所有分包的 Hub。MCP 至少必須：
- 維護並負責監督 MCP 合約所有適用條款和承保服務的合規性，無論分包層數有多少。
- 指明所有委託活動、義務及相關報告責任（如適用）。
- 在分包商協議和下游分包商協議中記錄 Hub 同意履行委託的活動、義務和報告責任（如適用）。
- Develop and maintain DHCS-approved policies and procedures to ensure subcontracted Hubs meet required responsibilities and functions.
- 如果分包的 Hub 也提供直接護理服務，因此除了是分包商或下游分包商之外也是網絡提供者，請確保 Hub 的提供者能力足以服務所有符合資格的 Medi-Cal 會員。
- 透過 MCP 合約的附件 J 向 DHCS 報告所有分包 Hub 的必要資訊，包括所有分包 Hub 的名稱、所提供的服務以及 Medi-Cal 會員所服務的一個或多個縣。
- Collect and review subcontracted Hubs’ ownership and control disclosures.
- 確保與分包 Hubs 簽訂的所有合約可在 DHCS 要求時提供。
當 DHCS 或 MCP 確定簽約的 Hub 未令人滿意地履行合約條款或任何 Medi-Cal 授權給他們的要求時，MCP 必須規定撤銷授權的活動或義務，或指定其他補救措施，包括糾正行動和/或經濟制裁。
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：按分包類型劃分的 MCP 監督與合規要求
| 分包類型 | MCP 監督與合規要求 |
|---|---|
| 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. |
| 部分委託分包商或下游部分委託分包商 | 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：MCP 與樞紐之間的合規活動範例
| 範例 | 合規要求 |
|---|---|
| MCP 將條款裁定和付款委託給一個中心 | 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 將提供者註冊和資格認證委託給 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. |
MCP-Hub 合規要求清單
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.
MCP 至少必須：
- 監督 MCP 合約的遵守情況。
- 在分包商協議中納入明確條文，概述所有委託活動、義務及相關報告責任。
- 制定並維護 DHCS 批准的政策和程序，以確保分包商履行規定的責任和職能。
- 透過 MCP 合約的附件 J 向 DHCS 報告所有分包 Hub 的必要資訊，包括所有分包 Hub 的名稱、所提供的服務以及 Medi-Cal 會員所服務的一個或多個縣。
- 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 Hub 代表 MCP 接受風險，請確保符合財務穩健性、人口需求評估 (PNA)、分包商網路充足性及醫療損失率 (MLR) 的要求。
- 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.
- 確保與分包商簽訂的所有合約和下游分包商協議可在 DHCS 要求時提供。
- Revoke delegation or provide other corrective actions if the Subcontractor’s or Downstream Subcontractor’s performance is not satisfactory.
第 3 節：資料與品質改善要求
與 Hubs 簽約管理和/或提供 Medi-Cal 福利的 MCP 必須遵守 MCP 合約和APL 23-006（或任何替代 APL）中規定的資料報告和品質改善 (QI) 要求。其他特定計劃的資料報告和 QI 要求也可能適用。
資料報告要求
MCP 必須有機制監控分包 Hub 對資料報告的遵守，包括驗證資料是否完整、準確、合理和及時的系統。這可能包括（但不限於）可支援 MCP 報告「遇見資料」的資料、每月 274 提供者網絡資料檔案、管理性護理計劃資料 (MCPD)、透過季度範本報告的資料、電子就診驗證報告，以及 DHCS 要求的任何其他特別資料要求，只要與分包 Hub 相關即可。
品質改善要求
MCP 對其分包商協議或下游分包商協議（如適用）中指定的分包中心的任何 QI 和健康公平職能負責。MCP 必須維持足夠的監督和監測，以確保所有委託的 QI 活動都能符合規定，至少包括
- 評估分包 Hub 執行委託活動的能力，包括初步判定分包 Hub 是否具有履行合約義務的行政能力、經驗和預算資源。
- 確保分包的中心符合 MCP 合約中規定的 QI 和健康公平要求。
- 確保 MCP 持續監控、評估和批准其對分包 Hub 的委託職能，包括至少每年或在 DHCS 要求時提供此監控和評估過 程的結果。
MCP 還必須確保分包的 Hub 遵守其「品質改善與健康公平轉型計劃政策與程序」(QIHETP)。
MCP-Hub 品質改善工具
MCP 對其分包商協議和下游分包商協議（如適用）中指定的分包商和下游分包商的任何品質改善 (QI) 和健康公平職能負責。MCP 必須維持足夠的監督與監控，以確保所有委託的 QI 活動都能符合規定。保持 NCQA 健康計畫認證的 MCP 必須確保遵循所有適用的 NCQA 標準和準則，以建立分包關係。
MCP 至少必須：
- 在委派任何職能給分包商或下游分包商之前，評估分包商或下游分包商執行委派活動的能力，包括初步判定分包商或下游分包商是否具有履行合約義務的管理能力、經驗和預算資源。
- 在適用範圍內，確保分包商和下游分包商符合 MCP 合約中規定的 QI 和健康公平轉型計劃 (QIHETP) 要求。
- 確保 MCP 持續監控、評估和批准其對分包商和下游分包商的委託職能，包括至少每年或在 DHCS 要求時提供此監控和評估過程的結果。
第 4 節：承擔財務風險或承保特定 Medi-Cal 會員群體的 Hubs 的額外考量
Hub 透過風險分擔和風險轉移安排來承擔 MCP 的財務風險。 代表 MCP 承擔財務風險的分包中心須接受更嚴格的監督和監控，以確保符合 Medi-Cal 要求。這包括與下列各項相關的要求：
- 財務可行性
- 人口需求評估
- 醫療損失率 (MLR)
財務可行性要求
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.
人口需求評估要求
人口健康管理 (PHM) 計劃確保所有 Medi-Cal 會員都能根據他們在整個護理過程中的需求，適當地獲得全面的服務。在 PHM 計畫下，MCP、其網絡及其合作夥伴（包括適用的分包商）負責根據標準化的架構和期望，滿足其服務社區內 Medi-Cal 會員的需求。這包括向 Medi-Cal 的利害關係人提供以下方面的存取資料：
- Medi-Cal 會員的健康記錄、需求和風險，以及其他支援風險分層的計劃資訊；評估和篩檢程序。
- 醫療、行為和社會支援。
- 分析和報告流程。
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.
醫療損失率 (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 報告和匯款要求限制的實體
| 實體類型 | 定義 | 受 MLR 限制？ |
|---|---|---|
| 分包商計劃 | 在服務區域內從 MCP 或其分包商或下游分包商承擔全部或部分委託風險的計劃。 | Maybe – see materiality threshhold info belo |
| 其他適用的分包商或下游分包商 | 分包商或下游分包商（分包商或下游分包商計劃除外）承擔風險，並從 MCP 或其分包商或下游分包商就其本身實體以外提供的服務（即，他們不直接提供給 Medi-Cal 會員的服務）收取付款。這可能包括 IPA、醫療團體、醫院系統或其他實體。 | Maybe – see materiaity threshold info below. |
| 非申報實體 | 網絡提供者、純行政分包商或下游行政分包商，以及不承擔風險或僅對其自身實體內提供的服務承擔風險的非適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.
重要性臨界值
MCP 必須使用 DHCS 設定的重要性臨界值來判斷分包或下游分包 Hub 是否須遵守 STC A11 報告和匯款規定。
就 CY 2023 MLR 報告年度而言，在 DHCS 修訂之前，適用的分包 Hubs 如果每年從單一上游實體收到一定金額的 Medi-Cal Capitation，作為在單一縣或評級區域提供服務的付款，並為此承擔風險且不直接提供服務，則須遵守 MLR 報告規定。低於年度臨界值的分包 Hub 無需就特定 MLR 報告年度進行報告，除非 DHCS 逐案要求。對於 CY 2023 MLR 報告年度，在 DHCS 修訂之前，Medi-Cal 人頭費的重大性臨界值為每年 $30,000,000，來自單一上游實體，作為在單一縣或評級區域提供服務的付款，適用的分包商或下游分包商承擔風險且不直接提供服務。
For more information about exemptions for newly contracted entities, and other details see APL 24-018 or any superseding APL.
第 5 節：MCP 監督責任摘要
適用於所有分包的 Hub：
- 監督和監測
- 合規
- 資料與報告
- 品質提升
適用於涵蓋 Medi-Cal 會員人口的分包 Hubs：
- 財務可行性
- 納入 PNA
對於承擔風險的分包 Hub：
- 檢查 MLR 是否適用
主要參考資料
2024 MCP Boilderplate 合約
管理照護所有計劃信函 (APL)
APL 23-001：網路認證要求
APL 23-006：授權與分包商網路認證
APL 23-020：及時支付索賠的要求
APL 23-029：醫療管理性護理計劃和第三方實體的諒解備忘錄要求
APL 20-017：報告管理性護理計劃資料的要求
APL 19-001：加州醫療保險管理式保健計劃網絡提供者地位指南
APL 24-018：分包商和下游分包商的醫療損失率要求
PHM 政策指南
ECM 政策指南
社區支持政策指南第 1 卷
社區支持政策指南第 2 卷