The Patient-Centered Medical Home (PCMH) model is advancing primary care by emphasizing patient-centric healthcare. This shift towards value-based models is gaining traction today. PCMH presents a promising framework for improving quality, patient satisfaction, and cost efficiency in modern healthcare systems.
What You Need to Know:
New York State has increased PCMH per member, per month (PMPM) incentive payments (retroactive to April 1, 2024):
- $10 PMPM for Medicaid and CHP patients under 21
- $8 PMPM for Medicaid patients 21+
To continue receiving these payments after March 31, 2025, practices must submit digital attestation to NYS by April 1, 2025.
To complete the attestation, you will need to have a high-level plan for how you can help your patients connect to the Social Care Networks (SCNs). For example, a practice that is not yet contracted with an SCN, can guide Medicaid patients towards SCN public-facing websites.
While you do not need to contract with an SCN to attest and receive enhanced payments, we recommend contacting your regional Social Care Network to establish referral relationships as soon as possible.
How to Complete the Attestation
Attestation Form: Complete your attestation here.
Password: MNYSPCMH25
Follow These Steps:
- Log in and search for your practice name.
- Confirm that the auto-populated information is accurate.
- Select your SCN referral workflow from the available options (see below for guidance)
- If needed, add multiple practice sites.
- Enter your name, role, and contact details, then click Submit.
If you’ve already attested, no further action is required.
Selecting established workflow with designated regional Social Care Network (SCN):
If you have already contracted with a regional SCN please refer to guidance from your SCN.
If you are not affiliated with an SCN you should reach out to the regional SCNs via email or website to share your interest in joining:
- Bronx: SOMOS SCN
- Long Island: HEALI
- Staten Island: Staten Island PPS
- Manhattan, Brooklyn, Queens: Public Health Solutions
Select the attestation response that most accurately represents your current or anticipated referral workflow to connect Medicaid patients to social care networks. Please note that you can select multiple workflow options.
Your SCN will give you further training and education during the onboarding process. In the meantime, you can direct your patients to SCN public websites.
What’s Next?
- Reach out to Maia Morse (mmorse@pcdc.org) from Primary Care Development Corporation if you have any questions about the attestation process or PCMH.
- Consider becoming a contracted entity with your regional SCN and provide screening and navigation services for your Medicaid members. Social Care Networks will provide onboarding and training.
- When you are ready to start screening patients reach out to MDLand to learn about the Social Care Hub, an integrated solution into iClinic® EHR. Our easy-to-use solution for Health-related Social Needs screening within iClinic. Contact us to explore how the Social Care Hub intertwines PCMH principles into your practice.