Statewide Patient-Centered Medical Home Incentive Payment Program

Date Issued: 7/30/2018

Revised Incentive Payments and Billing Guidance

Effective May 1, 2018, in accordance with the 2018-2019 enacted State budget, New York State (NYS) Medicaid changed the reimbursement amounts for providers working at practices that are recognized as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). The changes outlined in this policy reflect the standards and PCMH incentive payment amounts that were agreed upon as part of the enacted budget. The revised policy applies to both Medicaid Managed Care (MMC) and Medicaid Fee-For-Service (FFS).

Since its inception, the PCMH program has significantly grown. NYS Medicaid continues to make every effort to reward primary care providers (PCPs) who achieve PCMH recognition and provide high quality of care to New York Medicaid members.

This revised policy is in response to the fiscal constraints of the current Medicaid Global Spending Cap on the PCMH incentive payments and state efforts to increase participation in the PCMH program.

The table below summarizes, by provider type and recognition status, the MMC per-member, per-month (PMPM) amounts and the FFS “add-on” amounts for visits with qualified evaluation and management codes for the period May 1, 2018 - June 30, 2018.

Practices recognized under the NCQA 2014 Level 3, NCQA 2017, or NYS PCMH standards will receive a MMC incentive payment of $5.75 PMPM.

The PCMH FFS incentive payment add-on amounts will remain unchanged at $29 and $25.25 for professional and institutional claims, respectively. All incentive payments for PCMH-recognized providers under NCQA's 2014 Level 2 standards will be permanently eliminated for both MMC and FFS effective May 1, 2018.

PCMH Statewide Incentive Payment Program
MMC-PMPM and FFS ‘Add-on’ Amounts
Effective May 1, 2018 – June 30, 2018
Incentive
2014 NCQA
Level 2
Standards
2014 NCQA
Level 3
Standards or APC
2017 NCQA
Standards
NYS PCMH
Standards
MMC-PMPM $0.00 $5.75 $5.75 $5.75
Professional FFS claim add-on $0.00 $29.00 $29.00 $29.00
Institutional FFS claim add-on $0.00 $25.25 $25.25 $25.25

Beginning July 1, 2018, the PCMH incentive amounts will change as shown in the table below:

PCMH Statewide Incentive Payment Program
MMC-PMPM and FFS ‘Add-on’ Amounts
Effective July 1, 2018
Incentive
2014 NCQA
Level 2
Standards
2014 NCQA
Level 3
Standards or APC
2017 NCQA
Standards
NYS PCMH
Standards
MMC-PMPM $0.00 $6.00 $6.00 $6.00
Professional FFS claim add-on $0.00 $29.00 $29.00 $29.00
Institutional FFS claim add-on $0.00 $25.25 $25.25 $25.25

*NYS Medicaid is planning to add Advanced Primary Care (APC) providers, who are Gates 2 and 3 recognized, into the PCMH incentive program once federal approval is obtained. Achievement of these gates represents a physician’s proven ability to coordinate and manage care for high-risk patients. They will be paid at the 2014 PCMH Level 3 rates.

https://www.health.ny.gov/health_care/medicaid/program/update
/2018/apr18_mu.pdf


Last Updated: 07/30/18
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