PCMH Changes for 2025

Article by Shannon Sawyer, BS – Director of Healthcare Operations.

Important NYS PCMH Update

Whether you are a primary care practice, a large hospital system, or an ACO, this information is important to you.

In a recent Medicaid update, released on December 4, 2024, New York State Department of Health (NYS DOH) announced an increase in New York State Patient-Centered Medical Home (NYS PCMH) incentives. NYS PCMH Recognized practices are now eligible to receive an incentive enhancement of $4 Per Member Per Month (PMPM) for Medicaid Managed Care (MMC) and Child Health Plus (CHPlus) members under 21 years of age, as well as $2 PMPM for individuals 21 years of age and older. This change in reimbursement will be retroactive to April 1, 2024. This retroactive payment will be in addition to the current incentive of $6 PMPM. Your MMC Plans are expected to calculate these retroactive payments and send them to all NYS PCMH recognized practices in their respective network. Source: New York State Medicaid Update – September Volume 40 – Number 11

In order to continue to receive these enhancements in 2025, NYS PCMH recognized practices are expected to engage with a Social Care Network (SCN). A SCN is a network comprised of Health-Related Social Needs (HRSN) service providers. A SCN is designed to collaborate with various stakeholders to address the comprehensive needs of patients and communities. The goal of these networks is to improve the quality of life of your patients. Collaborating with a SCN will assist you, as the primary care physician, to complete social drivers of health screenings and referrals, collaborating and co-managing the patient.

SCN Lead Entities

SCN Lead Entities are organizations with a deep understanding of their region, and ability to coordinate an ecosystem of partners. They are responsible for creating and managing networks to provide screening and navigation to Medicaid Members, and ultimately to ensure services are delivered to address HRSNs. To find the SCN Lead Entity in your region, refer to this link: Social Care Networks.

Next Steps, NYS PCMHs

  • Already a member of your SCN Leading Entity?
  • Need to partner with your SCN Lead Entity?
    • In January 2025
        • Add referrals to an SCN to your current referral workflow. Include your expectations for service and communication.
    • By March 31, 2025
        • Partner with the SCN Lead Entity in your demographic area.
        • Submit an attestation to NYS DOH using the link above.

How RMS can assist…

  • We have over 14 years of proven experience assisting physician practices and health systems to attain and maintain NYS PCMH Recognition.
  • We collaborate with our partnering organizations to assess and identify patient needs and establish linkages with community partners to ensure delivery of comprehensive patient-centered integrated care.
  • We are adept in understanding the ever-changing landscape of healthcare delivery and assist our clients to respond to these changes.
  • We understand the important role social drivers of health have on impacting overall health status.
  • We use clinical and demographic data to determine your most vulnerable populations and identify their needs to ensure that your clinical and non-clinical staff are equipped with the resources that are essential to assist patients with accessing community resources.
  • We customize our consulting approaches to reflect the uniqueness of the patient demographic mix as well as geographic location of the practice and associated access to essential services.
  • We strive to develop organizational unity through cultural competency development and responsiveness to unique patient needs.
  • We provide PCMH related training for your teams, such as care coordination, care management, establishing SMARTIE[1] goals as well as operationalizing workflows to enhance efficiency.
  • We work with you to determine and achieve realistic goals for your practice using data and insights identified through our collaborative consulting partnership.
  • We meet your practice where you are, understanding the unique challenges that physician practices face and work with your team to develop processes to address the ever-changing patient needs.
[1] From SMART to SMARTIE Objectives

If you would like more information on how RMS can assist you, please contact Shannon Sawyer, Director of Healthcare Operations at shannons@rmsresults.com.


About the Author – Shannon Sawyer

Shannon has over 20 years of experience in the healthcare industry, specifically with care management, program oversight, and assisting physician practices in transforming their operations to optimize patient outcomes, as well as become more efficient. Shannon provides oversight to the healthcare transformation team, providing valuable insights on various initiatives related to regulatory compliance and practice management techniques. Shannon is also very active in her community, serving on the Board of Directors for the non-profit organization Parents of Special Children, as well as a designated Ambassador for the Fulton Block Builder Program.


Interested in conducting a market research project with RMS?

Contact our Vice President of Corporate Development, Sandy Baker at SandyB@RMSresults.com or call 1-866-567-5422.


About RMS Healthcare

Since 2010, RMS Healthcare, a division of Research and Marketing Strategies, Inc., has been leading healthcare organizations to embrace operational changes to improve the quality-driven approach to providing patient-centered care delivery. We understand that every health system presents unique scenarios, challenges, and ultimately, a passion to succeed. We work closely with our clients to cultivate cohesive and long-term partnerships. We have extensive experience in aligning practices to develop, implement, and adopt processes to ensure sustainable success that embodies the tenants of the Patient-Centered Medical Home (PCMH) model of care delivery, experience in leading Federally Qualified Health Centers (FQHC) through the certification process. RMS Healthcare also has extensive experience in providing targeted healthcare consultative services based on unique client needs.


About RMS

Research & Marketing Strategies, Inc. (RMS) is a full-service market research firm in Central New York. Formed in 2002, RMS helps organizations that are looking to know more about their customers and/or potential customers. They conduct surveys, focus groups, mystery shopping, studies and analysis. Each project is customized and gets personal attention by the best in the business. RMS has a reputation for getting results and offers an independent means to conduct telephone, on-line and mail surveying, In-depth interviews, intercept interviews, and participant recruitment as well as focus group hosting through QualiSight, its onsite call center and focus group facility. Taking advantage of the region’s reputation for being a great market study barometer, RMS recruits and moderates for focus groups, community forums and town meetings.

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