New York Medicaid’s Statewide Patient-Centered Medical Home Incentive Program Practitioner Quick Reference

1. What is the New York Medicaid’s Statewide Patient-Centered Medical Home (PCMH) Incentive Program? 
   The New York State Legislature passed a law in 2009 authorizing the state Department of Health to implement an initiative promoting the development of patient-centered medical homes by providing incentive payments. The goal is to improve health outcomes through better coordination and integration of patient care for New York state Medicaid, Health and Recovery Plan (HARP), and Child Health Plus program enrollees.
2. What is a medical home? 
   The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association have jointly defined a medical home as a model of care wherein each patient has an ongoing relationship with a personal physician who leads a team taking collective responsibility for patient care. The physician-led care team is responsible for providing all the patient’s health care needs, and when needed, arranges for appropriate care with other qualified practitioners or specialists. The Patient-Centered Medical Home is a proactive model of care that seeks to strengthen the physician-patient relationship by replacing reactive, episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. A medical home also emphasizes care through open scheduling, expanded hours, and improved communication between patients, practitioners, and staff.
3. When did the program go into effect? 
   The program became effective on July 1, 2010, for all practitioners recognized by the National Committee for Quality Assurance’s (NCQA) Physician Practice Connections PCMH Recognition Program.
4. Which lines of business/products are included in the program? 
   Medicaid, HARP, and Child Health Plus.
5. Will this affect the payments received for services provided? 
   Medical home incentive payments are not part of your contracted fee schedule, nor will these payments replace claims for primary care service we remit to practitioners. It will not affect other payments.
6. Are payments issued on an individual or group basis? 
   Payments are issued to the Tax ID number associated with the recognized service location.
7. What types of practitioners are eligible to receive the additional payment? 
   According to New York State Department of Health guidelines, office-based primary care physician practices, registered nurse practitioner practices, Federally Qualified Health Centers, and Diagnostic and Treatment Centers that are recognized by NCQA and NYSDOH, and who participate in Medicaid, HARP and Child Health Plus programs, are eligible to receive these additional incentive payments.
8. How does a practitioner qualify for payment? 
   Practitioners qualify for payment if they are primary care providers and the NCQA recognizes their practice as a medical home. Practitioners must also participate in Medicaid, HARP and Child Health Plus. Incentive payments are determined by the recognition level achieved in the NCQA Patient-Centered Medical Home Recognition Program and the number of patients in their care who are enrolled in the eligible lines of business.
   
   Effective April 1, 2025, providers may receive a PCMH incentive enhancement for referring patients to regional Social Care Networks (SCNs) and attesting to participation.
9. How does a practitioner become NCQA-recognized? 
   Please visit the NCQA’s website for details on the standards required to become a Patient-Centered Medical Home and for information on how to apply for recognition.
10. How is the bonus payment for each NCQA recognition level determined? 
    Payments will be determined by the NCQA’s Patient-Centered Medical Home Recognition Program level achieved after meeting specific elements in nine standard categories. Payment is calculated by multiplying the level achieved in the NCQA recognition program by the number of Medicaid, HARP, and Child Health Plus patients who have selected the eligible practitioner as their primary care provider (panel size). Payment from EmblemHealth is based on the number of Medicaid, HARP, and Child Health Plus members on your practice panel. For current payment levels, please see the latest guidance released on NYSDOH.
11. How is the Patient Centered Medical Home (PCMH) Incentive Enhancement payment determined?

Retroactive to April 1, 2024, all NYS PCMH-recognized primary care providers will receive a $2 incentive enhancement in addition to the current $6 per member per month (PMPM), for members 21 years of age and older; and $4 for members under 21.

Providers will receive $10 for Medicaid and Child Health Plus members under the age of 21, and $8 for Medicaid and HARP members 21 and over. EmblemHealth will issue a one-time retroactive payment for April to June 2024 for the difference between the previous $6 rate and the new rate.

Effective April 1, 2025, to continue to receive the incentive enhancement, providers will be required to refer their patients to the regional Social Care Networks (SCNs) and complete the attestation available on the New York State Health Commerce System (HCS) website.

EmblemHealth will calculate provider payment based on the “SCN indicator” provided by NYS. Providers that do not attest to participation in an SCN will receive the $6 PMPM payment without the incentive enhancement.

1. How is the panel size for a given month determined? 
   Panel size is determined by the Medicaid, HARP, and Child Health Plus members assigned to the practitioner. The state sends a monthly roster of NCQA-recognized practitioners. EmblemHealth matches the practitioners in its networks based on the address on file.
2. How often are payments issued? 
   Payment will be issued biannually for the periods of April through September and October through March to align with the state’s fiscal year.
3. How will payments be sent? 
   Payments are sent based on the corresponding Tax ID number on file with EmblemHealth.
4. How will a practitioner receive payment if recognized as a medical home at different locations? 
   Members are associated with only one location. The practitioner will receive payments for the Medicaid, HARP, and Child Health Plus members at each recognized site. If the two locations are under the same Tax ID number, then only one payment will be issued combining the members at each location.
5. Can a practitioner receive multiple payments for the same location? 
   Payments are issued by Tax ID number. If the practitioner has more than one Tax ID number for primary care providers selected by our Medicaid, HARP, and Child Health Plus members at this practice location, the practitioner will receive multiple payments. Practitioners that receive multiple payments in error should call 866-447-9717.
6. Why has a practitioner who is on the New York State medical home practitioner list not received payment? 
   There may be a delay in payment due to when the state placed the practice on the monthly list and when that information was received by EmblemHealth.
7. How does a practitioner assigned an inaccurate recognition level have it corrected? 
   EmblemHealth does not control this information. The data is provided by NCQA and New York State. You may email NCQA at ptc-pcmh@ncqa.org to address this issue.
8. What should a practitioner do if the practitioner thinks the payment is not accurate? 
   Accuracy depends on two factors:
   • If the number of members or the payment amount is incorrect, EmblemHealth will investigate and respond to you.
   • If the level or effective date of a practitioner’s recognition is not accurate, the practitioner should contact NCQA by emailing ptc-pcmh@ncqa.org or call the New York State NCQA Accreditation Report Hotline at 518-486-9012.

Once the issue is identified and a resolution is found, the adjusted payment will be made.

Additional questions about this initiative may be directed to New York State at the number noted above.