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Managed Care Policy and Planning Updates – June 2025

The Situation Report | June 16, 2025

On June 12, 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, Patient Centered Medical Home Program updates, Social Adult Day Care, 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. OMH will send the 2nd notice when the approval is received. MMCPs will have 90 days from the 2nd notice to complete system configuration and retrospective reconciliation.
  • Effective July 1, 2025, new network adequacy regulations relating to appointment wait time standards will take effect. In general, MMCPs must ensure that an enrollee can be offered initial appointments with providers within ten business days and within seven calendar days for appointments following hospital or ER discharge.

Patient Centered Medical Home Program

  • Retroactive to April 1, 2024, all PCMH-recognized Primary Care Providers will receive an incentive enhancement (in addition to the current $6 per member per month (PMPM) payment. $4 PMPM for Medicaid Managed Care (MMC) enrollees and Child Health Plus (CHPlus) members under 21 and $2 PMPM for enrollees 21 and over.
  • Practices submitting attestations after April 1, 2025, will forfeit monthly incentive enhancement payments ($2/$4) until the attestation is received. Practices will continue to receive the current $6.00/PMPM. As of June 1, 91% of PCMH providers have attested.
  • DOH will be introducing quality reporting and eventually a quality performance component to the PCMH program.  Practices that do not complete the SCN referral attestation or do not report on the required quality metrics will forfeit the incentive enhancement but will still qualify for the PCMH base payment of $6 PMPM as long as all NYS PCMH eligibility criteria is met. Additional details will be published in DOH’s May 2025 Medicaid Update.

Bureau of Managed Care Fiscal Oversight Updates from DOH

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

  • This month, the Department will issue Instructions for the Provision of Medicaid Managed Care-Specific Information within Medicare Advantage Dual Special Needs Plan Marketing and Communications. The Instructions will provide IB-Dual and MAP plans with Medicaid Managed Care-Specific Information to include on Medicare Advantage (MA) Dual Special Needs Plan (D-SNP) Marketing and Communications. Plans will be required to submit the MA D-SNP materials described in the Instructions for Department approval prior to use.
  • 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) are due July 11, 2025.
  • Value Based Payment (VBP) tracking Report (VBPTR) for the 1Q of SFY 2025-2026 (4/1/2025-6/30/2026) will be posted early July 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) will be posted by early July 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. Guidance on Home and Community Based Services Compliance Review Questions: This updated webpage is an important resource for preparing for the SADC HCBS Site Compliance Reviews.
  1. MLTC Plan SADC Contracting Oversight Roles and Responsibilities: This webpage provides guidance for MLTC plans on requirements when contracting with SADC programs.

NY Independent Assessor Program

According to DOH, in April 2025, there were a total of 7,067 requests for Initial Assessments.  The April call volume included 37,661 incoming calls, with an abandonment rate of less than 2 percent.  The Independent Assessor also mailed 9,962 outcome notices in April. 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.