New York State Updates PCMH and APC Incentive Payment Program

New York State (NYS) supports the National Committee for Quality Assurance's (NCQA) Patient-Centered Medical Home (PCMH) programs and the Advanced Primary Care (APC) program by allowing providers with PCMH or APC recognition to receive Medicaid or Child Health Plus (CHP) incentive payments, in the form of either per member per month (PMPM) capitation payments for Medicaid Managed Care (MMC) and CHP members, or as a per-visit "add-on" payment for eligible claims billed for services provided to Medicaid Fee-For-Service (FFS) members.¹

Recently, NYS announced updates to its PCMH and APC Incentive Payment programs, which may affect the payments received by providers. Updates were included in the November 2018 NYS Medicaid Update.

Policy updates include:

• NYS’s transition to an exclusive model for primary care known as the New York State Patient-Centered Medical Home (NYS PCMH). Any practice newly seeking PCMH recognition, or practice currently recognized under 2014 and 2017 NCQA PCMH upon expiration of their current recognition period, must meet the NYS PCMH criteria for continued participation in the PCMH and APC incentive payment programs.
• Modification to the Medicaid Fee-for-Service claims processing system to ensure that PCMH or APC incentive payments are only made for primary care or preventive medicine services when rendered in a clinic setting.
• Addition of CHP incentive payment to providers recognized as APC; APC2 recognized providers are only eligible for PCMH incentives for CHP insured on or after Sept. 1, 2018.

The Medicaid Update also clarified incentive payment guidance to include:

• Medicaid managed care lines of business eligible to received PCMH and APC incentive payments and plans for which PMCH incentive payments are not eligible.
• Medicaid FFS providers will be paid add-on incentive payments, effective the month the provider achieves their PCMH or APC recognition.
• Medicaid managed care plans are required to pay PCMH incentive on a per member per month basis to recognized providers for the entire recognition period, starting with the entire first month of recognition; prorated incentive payments are not permitted.

The below table provides the PCMH Incentive Payment Programs effective July 1, 2018:

Incentive	APC Gate 2	2014 – Level 3 NCQA PCMH Standards	2017 NCQA PCMH Standards	NYS PCMH Standards
PMPM add-on for Mainstream MMC, HIV SNP, and HARP Providers	$6.00	$6.00	$6.00	$6.00
PMPM add-on for CHP Providers	$6.00 (Effective 9/1/18)	$6.00	$6.00	$6.00
FFS Incentive add-on for Professional Claims	$29.00	$29.00	$29.00	$29.00
FFS Incentive add-on for Institutional Claims	$25.25	$25.25	$25.25	$25.25

What Does CohnReznick Think:

Eligible providers considering attaining PCMH recognition should contact the state to understand available resources offered at no-cost to support efforts implementing NYS PCMH. For more information, access the NYS Practice Transformation Agents page.

Providers must routinely review the National Committee for Quality Assurance (NCQA) Recognized Clinician Directory and report changes in a timely manner. Routine review and notice of change to NCQA, or the technical assistance advisor that assisted providers in achieving recognition, will ensure PCMH-recognized providers receive PCMH incentives.

CohnReznick encourages providers to complete an assessment of its compliance with the Medicaid FFS billing requirements and review received PCMH incentive payments for potential missed revenue opportunities.

Contact

Peter Epp, Partner, Healthcare Industry Practice
peter.epp@cohnreznick.com
646.254.741

Dolores Di Re, Senior Manager, Healthcare Industry Practice
dolores.DiRe@cohnreznick.com
646.625.5703

This has been prepared for information purposes and general guidance only and does not constitute legal or professional advice. You should not act upon the information contained in this publication without obtaining specific professional advice. No representation or warranty (express or implied) is made as to the accuracy or completeness of the information contained in this publication, and CohnReznick LLP, its members, employees and agents accept no liability, and disclaim all responsibility, for the consequences of you or anyone else acting, or refraining to act, in reliance on the information contained in this publication or for any decision based on it.