July 24, 2025

ACO Spotlight

New York State (NYS) Medicaid and Child Health Plus (CHPlus) Patient Centered Medical Home (PCMH) Program Evolution


In 2024, NYS Medicaid and CHPlus announced a NYS Patient Centered Medical Home (NYS PCMH) managed care incentive enhancement. This enhancement allows providers in a NYS PCMH that is recognized by the National Committee for Quality Assurance (NCQA) to earn additional PCMH dollars for Medicaid managed care and CHPlus members assigned to them. From 4/1/24-3/31/25, all NYS PCMH recognized providers were eligible for the incentive enhancement, as well as the PCMH base payment of $6pmpm (or $7pmpm for Adirondack Medical Home providers). As of 4/1/25, providers completing an attestation about social care network referral processes continued to be eligible for the enhancement.

To incentivize quality improvement within the NYS PCMH program, the NYS Department of Health intends to tie the incentive enhancement payment to quality in upcoming years.


Please note the following upcoming important program changes:

  • Social Care Network referral workflow attestations will transition to NCQA’s PCMH application/renewal system and eventually, the attestations will no longer be collected directly by the NYS Department of Health via survey. The NYS Department of Health survey will continue to be available until this transition occurs (addition details on the timeline will be announced at a later date).
  • NYS PCMH practices wishing to continue to earn the “incentive enhancement” (an additional $2 or $4 per month for each Medicaid managed care or CHPlus enrollee assigned to them) must report on select quality metrics.
  • These measures will be reported to NCQA during the NYS PCMH Transformation or Annual Reporting process. It is recommended that practices applying or renewing for the remainder of 2025 report on these metrics for Measure Year 2024 (MY24). While not a requirement for MY24, this recommendation is intended to prepare practices for reporting in future years; the incentive enhancement will not be contingent on MY24 reporting. Practices applying or renewing in 2026 will report on these metrics for Measure Year 2025 (MY25). Only practices that submitted MY25 data for the required quality metrics will continue to earn the incentive enhancement.*  Timeline and payment details are contingent on federal approval and a more detailed timeline will be released in a future update.


Required Quality Measures (The metrics below were selected from NCQA’s PCMH Standardized Measurement List. Pediatric practices report two of the four; adult practices must report three of the four):


  • Childhood Immunization Status: Combination 10 *pediatric practices must report*
  • Colorectal Cancer Screening *adult practices must report*
  • Diabetes HbA1C Poor Control (>9%) *adult practices must report*
  • Screening for Depression and Follow-Up Plan *pediatric and adult practices must report*


Performance goals will be set by the Department of Health for each required quality metric. In State Fiscal Year 2028 (April 1, 2027-March 31, 2028), only practices reporting quality measures and achieving a Department of Health-prescribed performance standard will continue to be eligible for the enhancement.


*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 $6pmpm (or $7pmpm for Adirondack Medical Home providers) as long as all NYS PCMH eligibility criteria is met.


The table below outlines the intended Medicaid and CHPlus managed care payment evolution for NYS PCMH recognized practices. Timeline and payment details are contingent on federal approval and are subject to change; any changes will be communicated by the NYS Department of Health.



Questions and Additional Information:


Registration is open for the 2025 North Country Leadership Summit, a collaboration between Adirondack Health Institute (AHI) and the North Country Telehealth Partnership, a joint effort between AHI and Fort Drum Regional Health Planning Organization (FDRHPO)!


Click the invite below to register, spots are folling up quickly!


Sponsorship Opportunities are Available!

 

Please return the Sponsorship PDF form to ahisummit@ahihealth.org. Deadline is Friday, August 8th.



Join regional and statewide leaders at the 2025 North Country Leadership Summit by becoming a sponsor of one of the premier events focused on advancing leadership and collaboration across sectors.


With premium sponsorship packages starting at $750, your organization can enjoy valuable exposure through:

  • Exhibitor tables in high-traffic areas
  • On-site and digital logo recognition
  • Full or half-page program advertisements
  • Speaking opportunities and session introductions
  • Access to the full attendee list (Title Sponsor only)


Title, Keynote, and Lunch Sponsorships offer top-tier visibility, while flexible options like Break Sponsorships and Exhibitor Tables are perfect for impactful brand presence.


Custom sponsorships also available to align with your marketing goals.


Findings from AHI’s Regional Data Survey


In February 2025, Adirondack Health Institute (AHI) surveyed our partners about their use of, and need for, population health and community resource information and data. We surveyed 95 individuals at 88 agencies, including CBOs, health care provider organizations, and other community partners in the North Country. Over the last few months, we have analyzed the feedback, identified themes, and established our next steps. Now, we want to share these results and findings with our partners.


Survey Response

Individuals from 40 different agencies completed the survey, giving us an impressive 45% response rate (thank you to those of you who participated!). These agencies service 10+ regional counties and represent a variety of organization types that are fairly evenly distributed between community-based service providers (52.4%, this includes community-based services organizations, offices for the aging, human services agencies, etc.) and health care providers (47.6%, this includes independent clinical providers, behavioral health providers, and care management agencies).


Insights

Our analysis of the compiled feedback led us to identify six separate insights about how our region’s organizations use and need population health and community resource information/data.


1) There Is Strong Overall Interest in Regional Data

  • This includes interest in both population health and community-based services data, with over 90% of respondents indicating their organization either currently uses, or has a need for, these types of information.
  • Interest is consistent for both community-based service providers (CSPs) and health care providers (HCPs).


2) Data Uses and Types are Aligned Across the Region but Tailored by Organization Type

  • Needs Assessment and Planning was the most common reported use of population health data – 86.8% of all respondents reported as a current or needed use of information.
  • SDOH/HRSN Prevalence was the most common reported type of used or needed population health data – 100% of all respondents reported it as a current or needed type of information.
  • Secondary Focus Areas
  • CSPs – Population health data relevant to generating grant applications and understanding available community resources.
  • HCPs – Population health data that informs benchmarking and understanding service utilization trends.


3) Data Source Interest Varies by Organization Type

  • CSPs are generally more interested in local/state data (Census Bureau, County Rankings, NYS).
  • HCPs lean more toward national data sets (CMS, CDC).


4) There is a Need for Versatile Presentation Tools

  • Alignment: All organizations are interested in having access to visual data summaries, particularly charts (61.9%) and tables (65.8%).
  • Secondary Tailoring: CSPs have more interest in having text summaries (81.0%), while HCPs have more interest in dashboard presentations (70.6%).


5) The Organizational Value of, and Barriers to, Data Analytics were Clearly Identified

  • Value: Data analytics were reported as highly valued across all organizations, with 76.2% of respondents reporting analytics as extremely or very valuable.
  • Barriers: The top barriers to accessing data and/or using data analytics were consistent across organization types:
  • Limited Staff Capacity (71.4%)
  • Limited Funding (50.0%)
  • Limited training/skills (40.5%)
  • Limited knowledge (38.1%)


6) There is a High Willingness to Consider Using a Centralized Data Repository, but Cost Sensitivity Exists

  • Interest in Centralized Data
  • 90.5% of respondents reported an interest in an AHI-maintained community-based services resource.
  • 95.2% of respondents reported an interest in a (general) centralized regional data repository.
  • Would Consider Paying for Data Analytics Services
  • 40.5% of respondents reported that they would be willing to pay for analytics.
  • 47.6% of respondents reported that they cannot afford to pay for analytics.


Next Steps

Based on this great feedback and the resulting insights, AHI has embarked on a Phase 1 Population Health Data Hub Pilot Project.


This internal project will involve: 1. Identification of high value population health data elements; 2. Development of database infrastructure; 3. Integration of the initial data sources into the database infrastructure; and 4. Testing of the population health database with an inactive grant application. Once this is complete, we hope to move into a Phase 2 pilot, testing the database with an external partner.


If your organization is interested in participating in our Phase 2 pilot, please reach out to Laura Morris at lmorris@ahihealth.org.


Nominate a GHNC Partner of the Year


The Get Healthy North Country Community (GHNC) Integrated Health Network will honor its first-ever Partner of the Year in 2025!

 

The goal of this recognition is to celebrate an exceptional partner who contributes significantly to the advancement of the GHNC Network's goals and objectives. The award also aims to increase visibility of effective chronic disease prevention programs and/or sustainability efforts within the GHNC Network. Additionally, we hope to encourage collaboration and knowledge-sharing among partners across the North Country region.

 

We wish to honor a Network partner who goes above and beyond to build a healthier future for the North Country through resource development, education, empowerment, and commitment to expanding access to chronic disease prevention in our communities.

 

Please click here to fill out the form to nominate your potential honoree.

 

Nominations must be submitted by July 31, 2025. The winner will be announced September 30, featured in a press release and social media posts, and in recognition posts for National Rural Health Day on November 20.

 

If you have questions about the GHNC Partner of the Year award, please contact Dan Sweet at dsweet@heartnetwork.org.

 Open Access at Caleo Counseling Services is available Monday through Thursday from 9:00 AM to 12:00 PM and 1:00 PM to 3:00 PM at 3043 State Route 4 in Hudson Falls.


Mental health clinicians’ availability may vary for mental health assessments, and treatment recommendations or referrals will be made as appropriate. Please note that Open Access services are for adults only.

A new edition of the Family Service Association of Glens Falls, Inc. newsletter is available.


Click here to read!

A new edition of the Moreau Community Center newsletter is available.


Click here to read!

Events

Other Information and Resources

Job Postings


Are you passionate about community health and making a real impact? Adirondack Health Institute is looking for dedicated professionals to join our team:


  • Regional Care Coordination Specialists (Clinton County - children)


Visit ahihealth.org/careers to apply!

Addiction and Mental Healthcare Access Assistance


AHI’s CHAMP (Community Health Access to Addiction and Mental Healthcare Project) program assists individuals and their families with accessing substance use disorder and mental health treatment services. We can help by breaking down barriers to care, including provider network and other health insurance related issues. We serve nine counties: Clinton, Essex, Franklin, St. Lawrence, Fulton, Hamilton, Saratoga, Warren, and Washington.


CHAMP is a FREE and CONFIDENTIAL service available to everyone, regardless of insurance coverage, including the uninsured.


Call us at 1.866.872.3740 or visit our website for more information.


Information sessions can be scheduled, and materials made available upon request – contact us for more details! 

Keep New York Covered

Important Changes to New York Medicaid, Child Health Plus, and the Essential Plan


Do you or a family member currently have health insurance through New York State Medicaid, Child Health Plus, or the Essential Plan? New York State has resumed eligibility reviews and renewals for people enrolled in these programs. This means you may need to take action to renew your health insurance or the insurance of your family members. 


Other big Marketplace changes for 2025 include the elimination of out-of-pocket expenses for pregnancy or diabetes-related services and continuous coverage for children under 6 who are enrolled in Child Health Plus or Medicaid!


Call AHI’s EASE enrollment team at 1.866.872.3740 or visit our site at ahihealth.org/knyc for more information.


Information sessions can be scheduled, and materials made available upon request – contact us for more details! 

Share Your Updates

AHI partners in Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren, and Washington counties are encouraged to send news items to communications@ahihealth.org to be considered for inclusion in the AHInformer.


Adirondack Health Institute | 100 Glen Street, Suite 1A, Glens Falls, NY 12801 518.480.0111 communications@ahihealth.org | www.ahihealth.org


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