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New York’s 1115 Medicaid Waiver: PCMH Enhanced Payment from CMS

Primary care doctor working at desk looking at the New York 1115 Medicaid Waiver information.

On Jan. 9, the Biden administration and CMS approved New York state's $7.5 billion Medicaid Section 1115 demonstration amendment. This New York Health Equity Reform amendment includes nearly $6 billion in federal funding, effective until March 31, 2027.  

Using these funds, "NYS seeks to build on the investments, achievements, and lessons learned from the Delivery System Reform Incentive Payment (DSRIP) 1115 waiver program to scale delivery system transformation, improve population health and quality, deepen integration across the delivery system, and advance health-related social need (HRSN) services," according to the New York State Department of Health

Under CMS’ 1115 waiver, participating New York state primary care practices with Patient-Centered Medical Home recognition from the National Committee for Quality Assurance are eligible to receive increased Medicaid Incentive Payment.  

Specifically, under Population Health, one of the three main NYHER programs, these primary care practices can receive additional enhanced payments starting April 1.  

Continue reading to learn more about: 

  • the seven goals of the Medicaid 1115 waiver in New York; 

  • the three program categories into which federal funding will be distributed; 

  • the start date for when New York state 1115 waiver payment increases begin; and 

  • how to renew your PCMH recognition. 

7 Goals of the 1115 Medicaid waiver in New York 

Since its adoption in 1997, the Medicaid 1115 waiver "has allowed the state to implement a managed care program which provides comprehensive and coordinated health care to Medicaid recipients, thereby improving their overall health coverage," according to DOH. The new amendment will focus on a wide range of initiatives, zeroing in on health equity advancement and access to primary and behavioral healthcare. 

The CMS Section 1115 waiver press release outlines the NYHER amendment's goals: 

  1. reduce costs and improve healthcare outcomes in vulnerable populations; 

  1. increase patient access to providers; 

  1. link patients to community resources, including critical housing and nutritional support services; 

  1. support patient-centered, health-equitable organizations; 

  1. establish sustainable base rates for safety net hospitals that serve the state’s most underserved communities;  

  1. enhance access to coordinated and comprehensive treatment for substance use disorders; and  

  1. make long-term, sustainable investments in the state’s healthcare workforce. 

For more information, refer to the NYHER 1115 Medicaid Redesign Team Waiver webinar slides

3 Program categories for federal funding 

The $6 billion in federal funding will be invested in three key areas: Social Care Networks, Strengthening the Workforce and Population Health.  

Together, these key areas seek to advance health equity, reduce health disparities and support the delivery of social care. Under the Medicaid Redesign Team (MRT) Waiver Amendment, DOH describes them as "targeted and interconnected investments that will augment each other, be directionally aligned, and be tied to accountability."  

Each key area has its own sub-areas: 

  • Social Care Networks: These cooperative regional networks will provide health-related social needs screening and referral services. They'll focus on housing, nutrition, transportation and case management. 

  • Strengthening the Workforce: Funding will go into two sub-areas: the Career Pathways Training Program and Student Loan Repayment. Both are aimed at building capacity through a reliable healthcare workforce pipeline, centering around opportunities to serve Medicare members or the uninsured. 

  • Population Health: This program contains five sub-areas: Medicaid Hospital Global Budgeting Initiative, Primary Care Delivery System Model, Health Equity Regional Organization, Substance Use Disorder Programs and Continuous Eligibility for Children 0-6. PCMH primary care practices can receive enhanced payments under the Primary Care Delivery System Model. 

When NYS 1115 waiver payment increases begin 

Starting on April 1, 2024, all existing PCMH-recognized practices and practices transforming can receive an enhanced payment in addition to their existing New York Medicaid $6 per member per month reimbursement. It’s important to note that the payment will not be received on this date, as the 1115 waiver continues to “iron out”. However, the sites will receive payment from April 1 and forward. 

The April 1 dollar amount is as follows:  

  • $4 additional for patients 0-22 years. 

  • $2 additional for patients 23+ years. 

This equates to either $10 or $8 dollars in total Per Member Per Month (PMPM). The payment progression is outlined below.

New York 1115 Medicaid Waiver payment progression chart.

How to renew your PCMH recognition 

Due to these enhanced payments, primary care practices with NCQA PCMH recognition should make sure they're on top of their requirements. PCMH recognition is granted for only one year. To renew your practice, you must report annually to NCQA and show that you maintained compliance with the PCMH criteria.  

If you have questions or need help with your PCMH annual reporting requirements for 2024, contact DataGen today. Our medical practice consulting solution takes the guesswork out of practice transformation. Not only can we help you achieve and sustain PCMH recognition, we can also ensure you're taking advantage of all the financial incentives available for your practice. 

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