PCMH
PCMH Reimbursement in New York: What Practices Can Earn
A 2026 guide to NYS PCMH managed-care PMPM payments, fee-for-service add-ons, quality reporting, Social Care Network attestation, and revenue modeling.
What are the 2026 NYS PCMH payment amounts?
The New York State Department of Health's 2026 Version 1 billing manual lists the following amounts effective January 1, 2026: New York State Department of Health
| Population/payment | With SCN attestation and required quality reporting | Without both conditions |
|---|---|---|
| Mainstream MMC, HIV SNP, and HARP; under 21 | $10 PMPM | $6 PMPM |
| Mainstream MMC, HIV SNP, and HARP; age 21+ | $8 PMPM | $6 PMPM |
| Child Health Plus; under 21 | $10 PMPM | $6 PMPM |
| Adirondack MMC; under 21 | $11 PMPM | $7 PMPM |
| Adirondack MMC; age 21+ | $9 PMPM | $7 PMPM |
| Adirondack Child Health Plus; under 21 | $11 PMPM | $7 PMPM |
| Medicaid FFS professional-claim add-on | $29 per eligible visit | $29 per eligible visit |
These figures are a source-backed 2026 snapshot, not a permanent fee schedule. Always check the current manual and plan guidance before billing or forecasting.
Who receives managed-care PCMH payments?
Managed-care plans calculate payments for attributed members assigned to a recognized provider in their network. New York supplies updated recognition information to plans, and payments are tied to the member, recognized clinician, site, plan, and recognition period.
A useful forecast therefore starts with the plan's attributed-member roster—not the practice's total Medicaid patient count. Reconcile plan rosters to the state's recognition file and the practice's NCQA record.
What is required for the enhanced PMPM?
For 2026, the state manual says newly recognized practices and practices that did not complete the prior attestation need a workflow to refer patients to a Social Care Network and a location-specific attestation. Practices must also report prescribed quality metrics for measurement year 2025 through NCQA's annual-reporting process. New York State Department of Health
The state lists four measures and varies the required set by patient population:
- Childhood Immunization Status—Combination 10
- Colorectal Cancer Screening
- Diabetes HbA1c Poor Control greater than 9%
- Screening for Depression and Follow-Up Plan
Pediatric practices report the designated pediatric measures, adult practices report the designated adult measures, and practices serving both populations follow the state's combined requirement. Confirm the current instructions rather than relying on a prior year's measure list.
How does the fee-for-service add-on work?
The 2026 manual lists a $29 professional-claim add-on for eligible Medicaid fee-for-service visits. Payment depends on claim-level requirements, including the recognized rendering provider, eligible procedure, service location information, member coverage, and other state billing rules.
Recognition does not make every claim eligible. Common reconciliation questions include:
- Is the rendering clinician on the current recognized-provider list?
- Does the nine-digit ZIP code match the recognized physical site?
- Is the patient eligible for the state PCMH payment population?
- Is the base visit or procedure eligible for the add-on?
- Does the patient have excluded third-party or dual coverage?
- Was the claim submitted and corrected within timely-filing limits?
Which populations are not included?
New York's 2026 guidance identifies included populations and exclusions. It states, for example, that members with Medicare as primary, other third-party health insurance, Essential Plan, Qualified Health Plan, Managed Long-Term Care, or PACE coverage are not paid through this PCMH add-on structure. Confirm current eligibility at the time of service. New York State Department of Health
How should a practice forecast managed-care revenue?
Use a plan-by-plan roster and separate age and program groups:
Attributed eligible members × applicable PMPM × recognized months = expected gross PMPM
Then adjust for roster lag, network status, member changes, recognition dates, reporting/attestation status, and payment variance. Do not use total visits in a PMPM forecast.
How should fee-for-service revenue be forecast?
Use eligible paid visits rather than unique patients:
Eligible recognized-provider visits × current FFS add-on = expected gross add-on
Remove visits with ineligible base codes, coverage exclusions, site mismatches, or other claim problems. Keep managed-care PMPM and FFS add-on calculations separate because they use different units.
Why do practices miss PCMH payments?
- A new clinician or location is not reflected in recognition files.
- The claim's rendering NPI or service ZIP does not match state data.
- Managed-care attribution rosters are not reconciled.
- The practice completes recognition but not the enhancement attestation or quality reporting.
- Payment lag is mistaken for permanent nonpayment.
- Denials are not assigned to an owner.
- Expected payments are calculated from the EHR population rather than payer data.
A monthly PCMH payment-control process
- Download the current recognition and payer attribution data available to the practice.
- Reconcile clinicians, sites, NPIs, and ZIP+4 details.
- Calculate expected PMPM by plan, population, and month.
- Calculate expected FFS add-ons from eligible visits.
- Compare expected amounts with remittance and capitation reports.
- Categorize variances by roster, recognition, eligibility, claim, or timing issue.
- Correct source data and claims, then track resolution.
This control turns recognition into collectible revenue rather than an unverified expectation.
Sources and methodology
Program rules and payment information are checked against the primary sources below. Verify current payer and Medicare locality requirements before billing.
- New York State Patient-Centered Medical Home — New York State Department of Health.
- 2026 New York State PCMH Billing Guidance — New York State Department of Health. Current recognition, quality-reporting, managed-care, and fee-for-service payment guidance.
- PCMH Attestation FAQs — New York State Department of Health.
- PCMH Annual Reporting — National Committee for Quality Assurance.
This resource is educational and is not legal, coding, billing, or financial advice. Program rules and payer policies change. Confirm requirements with CMS, your Medicare Administrative Contractor, New York State, NCQA, and applicable payers.