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Managed Care Policy and Planning Updates – July 2025

The Situation Report | July 21, 2025

On July 10, HCANYS participated in the state Department of Health (DOH) Managed Care Policy and Planning meeting. These meetings are held monthly with HCANYS and other associations representing managed care plans and are an opportunity to raise issues and concerns with DOH. 

Some of the important issues discussed in the meeting included Behavioral Health updates, Compliance Reviews by the Office of Medicaid Inspector General (OMIG), Social Adult Day Care, Managed Care Long Term Quality Incentive, Bureau of Managed Care Fiscal Oversight and the New York Independent Assessor Program. Below are some noteworthy highlights of the discussion. 

Behavioral Health 

Among other things, the Office of Mental Health (OMH) announced the following updates relating to rate changes, billing guidance and network adequacy: 

  • Medicaid Managed Care Plans (MMCPs) must complete necessary systems edits to ensure payable claims for dates of service October 1, 2024, and thereafter for OMH Partial Hospitalization at the newly effective rates. Additionally, MMCPs are required to conduct retrospective reconciliation to adjust payments for clean claims as necessary by August 4, 2025. 
  • Effective April 1, 2025, the mental health outpatient service rates have been increased to reflect a legislatively mandated 2.6 percent cost of living adjustment (COLA), which is consistent with the State Fiscal Year (SFY) 2025-26 Enacted State Budget and will be reflected in premiums upon NYS and Federal approvals. OMH is developing the MMCP Rate Announcement memo. The rate is pending DOB approval.  
  • DOH distributed the MMCP Rate Announcement memo on July 1, 2025.  The rate is pending DOB approval. OMH will send the second notice when the approval is received. MMCPs will have 90 days from the 2nd notice to complete system configuration and retrospective reconciliation. 

Office of Medicaid Inspector General (OMIG) Compliance Reviews 

  • Compliance Program Reviews (CPRs) began July 3, 2023. There are three lookback periods that have been under review for three-month review periods: April 1 - June 30, 2023; July 1 - September 30, 2023; and, October 1 - December 31, 2023 
  • For reviews beginning after July 1, 2025, OMIG will use a 12-month review period for newly initiated CPRs. 
  • Review Activity: 148 reviews completed and 235 reviews actively in progress 

Bureau of Managed Care Fiscal Oversight Updates from DOH 

Among other things, DOH announced the following updates and reminders: 

Funding for the Managed Long Term Care Quality Incentive was removed from the FY 2026 state budget.  The 2024 Measurement Year Quality Incentive will be run according to our Methodology Document released in December 2023. The Department intends to release the 2024 Quality Incentive results on the public website as is done with the Medicaid Managed Care Quality Incentive and the Nursing Home Quality Initiative.  The release will rank plans according to performance, but will not include tier.  Plans will be notified when results are posted.  DOH intends to publicly release annual methodologies by year end for the upcoming measurement year 

  • Cost Reports for the 1st Quarter of 2025 were due on May 15. 
  • Medicaid Medical Loss Ratio (MLR) Report Resubmissions for SFY 2021-2022 (4/1/2021–3/31/2022) were due on July 11, 2025. 
  • Value Based Payment (VBP) tracking Report (VBPTR) for the 1Q of SFY 2025-2026 (4/1/2025-6/30/2026) was posted recently and due August 1, 2025. 
  • Cost Reports (MMCOR, SNPOR, EPPOR, IBDOR, MLTCCR, MAPOR, PACEOR, FIDAOR) for the 2nd Quarter of 2025 (1/1/2025-6/30/2025) were recently posted and due August 15, 2025. 

Social Adult Day Care (SADC) 

The following resources for MLTC Plans and SADCs have been added to the SADC HCBS Compliance website for immediate use: 

  1. Resources for Person Centered Planning (PCP): This  new webpage providing quick references and tools to support MLTC plans and SADCs with planning individualized service for each member. 
  2. HCBS Compliance FAQ: The webpage has been expanded to address more frequently asked questions (FAQs) from MLTC plans and SADCs. 

NY Independent Assessor Program 

According to DOH, in May 2025, there were a total of 7,234 requests for Initial Assessments.  The May call volume included 36,275 incoming calls, with an abandonment rate of less than 4 percent.  The Independent Assessor also mailed 9,575 outcome notices in May. There were 51 clinical variance requests. 

For further information on these topics or any others discussed above, please contact HCANYS policy staff. Please know that HCANYS will continue to join and participate in the monthly DOH Managed Care Policy & Planning meetings and report back to you on the noteworthy developments and other highlights.