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 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 patientcentered 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, 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 of 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 Patient-Centered Medical Home Recognition Program.
  4. Which lines of business/products are included in the program?
    HIP Medicaid, HARP and Child Health Plus.
  5. Will this affect the payments received for services provided?
    Medical home incentive payment is 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 checks issued on an individual or group basis?
    Checks 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 physicians and the NCQA recognizes their practice as a medical home. Practitioners must also participate in HIP 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.
  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 as a result of meeting specific elements in nine standard categories.

    Effective April 2015:

    2008 Standards (PPC-PCMH)

    • NCQA Certification Level 2: $0 PMPM
    • NCQA Certification Level 3: $0 PMPM

    2011 Standards

    • NCQA Certification Level 2: $4 PMPM
    • NCQA Certification Level 3: $6 PMPM

    2014 Standards

    • NCQA Certification Level 2: $4 PMPM
    • NCQA Certification Level 3: $6 PMPM

    Effective January 2016

    2011 Standards

    • NCQA Certification Level 2: $2 PMPM
    • NCQA Certification Level 3: $4 PMPM

    2014 Standards

    • NCQA Certification Level 2: $6 PMPM
    • NCQA Certification Level 3: $8 PMPM

    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 physician (panel size). Payment from EmblemHealth is based on the number of HIP Medicaid, HARP and Child Health Plus members on your practice panel.

  11. How is the panel size for a given month determined?
    Panel size is determined by the members assigned to the practitioner on the last day of each month. The state will make available a monthly roster of NCQA-recognized practitioners. EmblemHealth will match the practitioners in its networks with members enrolled in its Medicaid, HARP and Child Health Plus programs as of the last day of that month.
  12. How often are checks issued?
    Payment checks will be issued quarterly.
  13. Where will checks be mailed?
    Checks are mailed to the billing address for the corresponding Tax ID number on file with EmblemHealth.
  14. Do eligible practitioners receive a detailed listing of the members they were paid for?
    Yes.
  15. 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 HIP 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 check will be issued combining the members at each location.
  16. Can a practitioner receive multiple checks for the same location?
    Checks are issued by Tax ID number. If the practitioner has more than one Tax ID number for primary care physicians selected by our Medicaid, HARP and Child Health Plus members at this practice location, the practitioner will receive multiple checks. Practitioners that receive multiple checks in error should call 1-866-447-9717.
  17. 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.
  18. 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 contact NCQA by emailing ptc-pcmh@ncqa.org to address this issue.
  19. 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 check 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 Accrediation Report Hotline at 518-486-9012.

    Once the issue is identified and a resolution found, the adjusted payment will be made in the month following the end of the quarter in which the inaccuracy was discovered.

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