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Managed Care Policy and Planning Updates – May 2025

The Situation Report | May 12, 2025

On May 8, 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, MCO Pregnancy Notifications, fiscal oversight, 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:

  • The mental health outpatient treatment and rehabilitative services (MHOTRS) quality improvement rates for hospital-based and freestanding providers in the OMH quality improvement collaboratives initiative increased from an additional 5.7% to an additional 8.5%, effective 10/1/24. The rate change is pending approval by the NYS Division of Budget (DOB).
  • The OMH Partial Hospitalization services rate has been increased by 25%, consistent with the State Fiscal Year (SFY) 2024-25 Enacted State Budget, effective 10/1/24. The DOB approved the change on 4/8/25. The rate change notification is in the process of being released.
  • Effective 7/1/25, OMH providers should use modifier 93 for eligible telehealth audio-only mental health services to align with CMS billing practices.
  • Effective 7/1/25, new network adequacy regulations relating to appointment wait time standards will take effect. In general, Medicaid Managed Care Plans 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. Text of the new regulations can be found here.

Pregnancy Notification

DOH indicated its goal to identify all pregnant members as early as possible to ensure proper education and support.  By providing a reminder to perinatal care providers about the importance of notifying health plans about patients’ pregnancies (including an easy way to refer a patient to these programs), DOH hopes to increase the number of referrals to the programs available. DOH does not expect any changes in services offered by health plans to support pregnant members. In June, DOH will publish an article in the Medicaid Update and send an email notification to the perinatal care providers via the eMedNYlistserv. For questions, please contact DOH at This email address is being protected from spambots. You need JavaScript enabled to view it..

Bureau of Managed Care Fiscal Oversight Updates from DOH

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

  • Revalidation notices have been sent to 87 MCOs and notices will be sent to the remaining MCOs over the next 9 months. MCOs that do not submit a complete revalidation package by the deadline specified in the notice will be terminated.
  • Cost Reports for the 1st Quarter of 2025 are due on 5/15/25.
  • Value Based Payment Tracking Report (VBPTR) for the 1st Quarter of SFY 2025-2026 will be posted early July and due August 1, 2025.
  • Cost Reports for the 2nd Quarter of 2025 will be posted early July and due August 15, 2025.
  • Essential Plan Medical Loss Ratio Report for 2024 will be posted by end of June and due 8/29/25.
  • Child Health Plus Medical Loss Ratio Report for 2024 will be posted by end of June and due 8/29/25.
  • Medicaid MLR Report for SFY 2021-2022 (4/1/2023-3/31/2024) are being reviewed.
  • Medicaid MLR Report for SFY 2022-2023 (4/1/2023-3/31/2024) were due March 29, 2024 and 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 Annual 2024 (1/1/2024-12/31/2024) were due April 1, 2025 and are being reviewed.
  • Value Based Payment Tracking Report (VBPTR) for the 4th Quarter of SFY 2024-2025 (4/1/2024-3/31/2025) were due April 29, 2025 and are being reviewed.
  • To facilitate meeting Federal requirements, DOH will follow an expedited timeline for completion of the reviews of the Annual 2024 Cost Reports. DOH will finalize 2024 cost reports, and the 2024 cost report software will be closed for resubmissions, by June 30, 2025. The Department will continue to work closely with your plan’s financial reporting teams to complete these reviews.

Social Adult Day Care (SADC)

DOH shared the following reminders and updates on SADC:

  • To make certain all contracted SADCs are in compliance, plans must review and confirm that member rights, as stated in regulation 9 CRR-NY 6654.20 and the HCBS Final Rule, are implemented in all programs, are documented, and are made available to all members. Further, DOH indicated that MLTC Plans must ensure that SADC programs update policies and member rights documentation as applicable, and post the member rights in a conspicuous area and make available to all members.
  • All completed SADC site evaluation tools from August 2024 and after, are due by Friday May 16, 2025. To simplify the submission of completed site evaluation tools, DOH set up individual MLTC plan spaces within the Secure Collaboration application in the Health Commerce System (HCS).

NY Independent Assessor Program

According to DOH, in March 2025, there were a total of 7,348 requests for Initial Assessments.  The March call volume included 39,006 incoming calls, with an abandonment rate of less than 3 percent.  The Independent Assessor also mailed 9,990 outcome notices in March. There were 32 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.