Managed Care Policy and Planning Updates – August 2025

The Situation Report | August 18, 2025

On August 14, 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, concerns, and questions with DOH.

Some of the important issues discussed in the meeting included Behavioral Health updates, Office of Medicaid Inspector General (OMIG) Managed Care Program Integrity Reviews, CPT Coding, Managed Care Contract Amendments, Fiscal Oversight, Social Adult Day Care, and the New York Independent Assessor Program. Below are some noteworthy highlights of the discussion

Behavioral Health

The Office of Mental Health (OMH) announced the following updates relating to billing and services:

  - On August 8, 2025, OMH announced a notification relating to Dual Diagnosis (DD) Inpatient Services. A DD Inpatient Services unit provides specialized inpatient psychiatric care to stabilize adults and children with co-morbid mental illness and intellectual developmental disability diagnoses, and is part of the covered managed care inpatient benefit. The purpose of the memo is to provide notification and billing updates for the DD-Inpatient Services program, and the system configuration requirements applicable to Mainstream Medicaid Managed Care Plans, HARPs, HIV SNPs, and MAP Plans.

  -  With respect to Certified Community Behavioral Health Clinics (CCBHCs) or Crisis Stabilization Centers (CSC), the State has not yet established a timeline for the Medicaid managed care carve-in, but will provide updates as more information becomes available

OMIG Managed Care Program Integrity Reviews (MCPIR)

Pursuant to NYS Social Services Law §364-j(36)(b), OMIG must conduct periodic reviews of the contractual performance of each managed care provider as it relates to the managed care provider's program integrity obligations under its contract with the Department of Health (DOH).

OMIG is starting its first round of MCPIR on Managed Long Term Care plans with a Review Period from January 1, 2023 to December 31, 2023. OMIG is also conducting reviews on Mainstream Managed Care, HARP and SNP plans. OMIG, in consultation with DOH, shall publish on its website, a list of those contractual obligations pursuant to which the managed care provider's program integrity performance shall be evaluated, including benchmarks, prior to commencing any review.

Pursuant to SSL 364-j(36)(c), where OMIG determines that a Managed Care Organization (“MCO”) is not meeting its program integrity obligations under the Contract, OMIG may recover up to 2% of the administrative component of the Medicaid premium paid to the MCO for the period under review.

MCOs identified for review will receive from OMIG an Audit Notification Letter, which details the review process, timeframe, document submission instructions, and OMIG contact information.

The process includes a Draft Audit Report, Final Audit Report, and a Summation Letter. Various repayment options as well as hearing rights are also part of the process.

Category II CPT Code Claims

In May of 2025, NYS DOH published a Medicaid Update article requiring the submission of Category II CPT (F) codes when providers utilize global or bundled billing for perinatal services. In connection with the update:

• NYS DOH is requiring the submission of a separate claim with a Category II CPT (F) code for each perinatal (prenatal or postpartum) service provided to a NYS Medicaid member at the time the service is rendered
• NYS DOH is not requiring the addition of Category II CPT (F) codes on global or bundled perinatal service claims
• Category II CPT codes are non-reimbursable, but it is allowable to submit the claim with a $.01 charge, if needed, for the claim to be generated/accepted

In December 2024, NYS DOH published a Medicaid Update announcing approval from the Centers for Medicare & Medicaid Services to provide an additional payment to the current NYS Medicaid reimbursement for comprehensive, timely postpartum visits provided to Medicaid Managed Care (MMC) enrollees for deliveries that occurred from July 1, 2024, through March 31, 2025. Providers must submit either a 59430 or 0503F claim, attesting that a timely postpartum visit occurred to be considered for the postpartum visit incentive payment. The timeline for calculating and distributing the payment incentive has been updated:

Bureau of Managed Care Fiscal Oversight Updates from DOH

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

• CMS asked New York to advance the target submission date for the 1st Amendment to the ’24-’29 MMC/HIV/SNP/HARP Contract from November 2026 to December 2025. To meet the deadline, DOH revised the amendment to include NY’s highest priority items and all required compliance identified by CMS. Items to be included in the 1^st Amendment include (but are not limited to) wage parity, Indian health care providers, Family Health Plus Removal, and Social Care Networks Carve-in. Stakeholders can expect to receive remaining edits for review and comment in September.
• Cost Reports for the 2nd Quarter of 2025 are due 8/15/25.
• Essential Plan Medical Loss Ratio Report for 2024 is due 8/29/25.
• Child Health Plus Medical Loss Ratio Report for 2024 is due 8/29/25.

• Medicaid MLR Report for SFY 2022-2023 (4/1/2022-3/31/2023) were due on 3/29/24 are being reviewed.

• Medicaid MLR Report for SFY 2023-2024 (4/1/2023-3/31/2024) were due March 28, 2025 and are being reviewed.
• Cost Reports (MMCOR, SNPOR, EPPOR, IBDOR, MLTCCR, MAPOR, PACEOR, FIDAOR) for the 1^st Quarter of 2025 (1/1/2025-3/31/2025) were due 5/15/25 and are being reviewed.
• Medicaid Medical Loss Ratio (MLR) Report Resubmissions for SFY 2021-2022 (4/1/2021–3/31/2022) were due July 11, 2025 and are being reviewed.
• Value Based Payment Tracking Report (VBPTR) for the 1Q of SFY 2025-2026 (4/1/2025-6/30/2025) were due August 1, 2025 and are being reviewed.

Social Adult Day Care (SADC)

DOH shared the following reminders and updates on SADC:

- MLTC plans are required to upload SADC site evaluation tools which were completed between August1, 2024 –July 31, 2025, to the Secure Collaboration platform by August 15, 2025. MLTC plans that fail to complete or submit site evaluation tools for all contracted SADC sites may be issued a Statement of Deficiency (SOD).

- To ensure members receive appropriate and individualized services, MLTC Plans must share Person Centered Service Plans (PCSP) with all relevant service providers, which include SADC programs. The Department encourages MLTC plans and their contracted SADC programs to discuss the process of sharing information, including member PCSPs, and include any such requirements in the SADC/MLTC plan contract.

NY Independent Assessor Program

According to DOH, in June 2025, there were a total of 6,894 requests for Initial Assessments.  The June call volume included 33,455 incoming calls with an abandonment rate of less than 5 percent.  The Independent Assessor also mailed 9,499 outcome notices in June. There were 48 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.