Frequently Asked Questions: Patient Centered Medical Homes

A1. PCMH is a model of care where each patient has an ongoing relationship with a personal physician and a care team. The physician and care team take collective responsibility for meeting all of the patient´s health care needs. The National Committee for Quality Assurance´s (NCQA) PCMH recognition is awarded to practices and their providers that meet a set of predetermined standards for improving primary care. Visit NCQA´s website to find more information about achieving PCMH recognition as well as eligibility criteria. http://www.ncqa.org/programs/recognition/practices/patient–centered–medical–home–pcmh

New York State Medicaid has an incentive program known as the New York Statewide Medicaid PCMH Incentive Payment Program that provides additional reimbursement to high–level NCQA PCMH–recognized practices.

Q2. My practice is currently NCQA PCMH–recognized. What incentive amounts are we eligible for under the New York Statewide Medicaid PCMH Incentive Payment Program?

A2. The table below reflects the current incentive payment amounts. Recognized practices will be notified of any changes in payment amounts prior to an effective date by the email(s) provided to NCQA at the time the application was submitted.

PCMH Statewide Incentive Payment Program PMPM and ´Add–on´ Amounts Effective July 1, 2017
2011 Standards NCQA Level 2	2011 Standards NCQA Level 3	2014 Standards NCQA Level 2	2014 Standards NCQA Level 3	2017 Standards
MMC – PMPM	$0.00	$0.00	$3.00	$7.50	$7.50
FFS Add–on Per Visit: Professional Claims	$0.00	$0.00	$20.50	$29.00	$29.00
FFS Add–on Per Visit: Institutional Claims	$0.00	$0.00	$23.25	$25.25	$25.25

PCMH Statewide Incentive Payment Program PMPM and ´Add–on´ Amounts Effective May 1, 2018 – June 30, 2018
2014 Standards NCQA Level 2	2014 Standards NCQA Level 3	2017 Standards
MMC – PMPM	$0.00	$2.00	$2.00
FFS Add–on Per Visit: Professional Claims	$0.00	$29.00	$29.00
FFS Add–on Per Visit: Institutional Claims	$0.00	$25.25	$25.25

Q3. My practice is currently participating in the Multipayer Adirondack Medical Home Demonstration. What are the Medicaid incentive reimbursement amounts given for participation in this program?

A3. The Medicaid Managed Care payment is $7 per member per month and the Medicaid FFS add–on amount, for both professional and institutional claims, is $40.50 as of January 1, 2017.

Q4. What enrollee populations are covered as part of the New York Statewide Medicaid PCMH Incentive Payment Program?

A4. Populations that are covered in the New York Statewide Medicaid PCMH Incentive Payment Program include: Medicaid Managed Care (MMC), Medicaid Fee–for–Service (FFS), Child Health Plus (CHP), HIV Special Needs Plans (HIV SNP), and Health and Recovery Plans (HARP). Please see the June 2016 Medicaid Updatefor more information.

Q5. How will I be paid by health plans for MMC, CHP, HIV SNPs and HARPs?

A5. Practices will be paid on a schedule determined by each individual MMC plan with which they participate. Plans distribute MMC payments at least two times per year, but may be distributed more frequently. Questions regarding payment distribution frequency should be directed to individual MMC plans.

Q6. How will I be paid by Medicaid FFS?

A6. Medicaid FFS claims are paid on a billing cycle set by eMedNY. The FFS incentive is reflected on the explanation of benefits summary. Questions regarding FFS claims can be directed to the eMedNY call center at 1–800–343–9000.

Q7. What criteria is necessary on an eligible Medicaid FFS claim to ensure receipt of the PCMH add–on incentive?

A7. It is necessary for both institutional and professional claims to contain the correct physical location address of the practice, including the 9–digit zip code, clinical group NPI, individual servicing provider´s NPI, and an Evaluation and Management (E&M) code designated by New York State Department of Health (NYS DOH) as primary care. The claim paid amount must be greater than zero. For a list of eligible E&M codes please see the February 2015 Medicaid Update.

Institutional claims must also include an eligible rate code. Eligible rate codes are also listed in the February 2015 Medicaid Update.

For professional claims, the place of service code on the claim must be equal to 11(office). Institutional and Professional claims are not eligible for the PCMH incentive if they contain a third–party payment such as Medicare, or commercial insurance.

Q8. Our practice just hired a new physician, how do we notify NCQA and the NYS DOH?

A8. You can add and remove providers from your current recognition at any time. For more detailed information on this process please visit NCQA´s Frequently Asked Questions page: Practice Changes: Adding and Deleting Clinicians. The NYS DOH will automatically be notified on a monthly basis from NCQA.

Q9. How long will it take for payments to come through upon new recognition?

A9. After a practice obtains a new recognition, it make take between 60–90 days to receive payments reflective of a new recognition.

Q10. How long will it take for rate adjustments to take effect if our practice upgrades our recognition with NCQA to a higher standard?

A10. After a practice upgrades a current recognition, it may take between 60–90 days for a health plan or eMedNY to receive notification of the change. Payment changes will be reflected in the next payment cycle as determined by the health plan or eMedNY.

Q11. Where can I find updates regarding the New York Statewide PCMH Incentive Payment Program?

A11. The Medicaid Update is a monthly newsletter that contains program and policy changes. To view the most recent Medicaid Update visit the DOH Medicaid Updatewebsite.

Q12. Is there a discount for PCMH applications and how does my practice apply for the discount?

A12. The New York State Department of Health (NYSDOH), in partnership with the National Committee for Quality Assurance (NCQA), is permitted to offer a sponsorship code (a 20% discount) to clinicians who participate with Medicaid in New York and are applying to NCQA for new Patient Centered Medical Home (PCMH) recognition. The discount code may be applied to pre–clinician submission fees for the 2014 or 2017 PCMH recognition programs. Because NCQA offers multi–site practices of three or more independent sites a 50% discount per clinician application fees, such practices are not eligible for an additional discount through this sponsorship.

The NYSDOH–sponsored discount code is available only to clinicians who currently participate with the New York State Medicaid program. The code ´GNYDOB´ can be entered into the ´discount code´ field of the NCQA PCMH online application any time prior to submission in order to apply a 20% discount. Questions specific to NYSDOH´s PCMH discount code can be sent to pcmh@health.ny.gov.

General questions about NCQA´s PCMH recognition, sponsorship program, or online application should be sent to NCQA via their online portal: http://ncqa.force.com/pcs/login.

Q13. How can I check if my practice recognition information is correctly on file with NCQA and the NYS DOH?

A13. Practices can use the NCQA Recognized Clinician Directoryto verify their recognition information. It is essential that the address on file with NCQA represents the physical site location of the practice (not a billing address) in order to get paid for the New York Statewide Medicaid PCMH Incentive Payment Program. The information displayed on this site is the same recognition information on file with the NYS DOH. To change practice information or update contact information, login to your MY NCQA account.

For all other questions please email the PCMH Unit in the Office of Quality and Patient Safety at the NYS DOH at pcmh@health.ny.gov