2026 NY Medicaid 1115 Waiver update: PCMH quality benchmarks

New York state has provided additional clarity on what Patient-Centered Medical Home practices will need to do to earn enhanced incentive payments under New York state’s Medicaid Section 1115 Demonstration Waiver.

In an Oct. 26 update, the New York State Department of Health outlined quality reporting requirements, established performance benchmarks and explained how practices can demonstrate improvement as the program evolves. The update reinforces a shift for New York state PCMH practices: achieving and sustaining PCMH recognition remains foundational, but quality performance will play a growing role in enhanced incentive payments. Here are the updates practices should have on their radar.

Enhanced PCMH incentive requirements are evolving

New York's enhanced incentive structure introduces progressively greater practice responsibility and accountability. As the program advances, requirements move from maintaining PCMH recognition and establishing Social Care Network referral workflows to reporting quality measures and demonstrating performance improvement. For practices, that means preparing for quality reporting isn't just about meeting a future requirement. The data being collected and reported will establish the foundation for measuring future performance. 

What changes and when

Source: DOH

The following DOH Required Quality Measures table outlines the intended NYS Medicaid and CHPlus MMC payment evolution for NYS PCMH-recognized practices. 

Which quality measures are included?

*Represents an update from previous DOH guidance. Source: DOH

Beginning with the April 2026 through March 2028 payment period, practices will report prescribed quality measures in NCQA's Q-PASS based on primary specialty type.

The measures identified by DOH include:

• childhood immunization status, combo 10;
• screening for depression and follow-up;
• colorectal cancer screening; and
• diabetes glycemic status assessment greater than 9%.

Not every measure applies to every practice. Reporting requirements are based on primary specialty type, making it important for practices to understand which measures apply to them and how they are performing against those measures.

Practices have two paths to meeting performance expectations

One of the most important parts of the latest update is DOH's explanation of how practices will be evaluated against established benchmarks. Starting April 2028 through March 2029, sites will be evaluated based on performance on the metrics, not just by reporting on the metrics.

Practices can satisfy the performance expectation for at least one reported measure in one of two ways:

1. Meet or exceed the established benchmark, or
2. Meet or exceed the practice's gap-to-goal improvement target.

That second option is important. A practice performing below the benchmark does not necessarily have to reach the full benchmark immediately.

Instead, the gap-to-goal methodology establishes an improvement target based on the distance between the practice's current rate and the benchmark. See the DOH chart below for quality measure benchmarks rationale.

Quality measure benchmarks rationale

Source: DOH

What does gap-to-goal improvement look like?

DOH provided an example using colorectal cancer screening to demonstrate the calculation.

A practice starts with a colorectal cancer screening rate of 55%, while the 75th-percentile benchmark is 77.1%.

Here's how the improvement target is calculated:

Source: DOH

What does that mean for the practice?

The practice doesn't need to jump from a 55% colorectal cancer screening rate directly to the 77.1% benchmark in this example.

Instead, applying the gap-to-goal methodology results in a 57.2% improvement target.

For a practice already meeting or exceeding the 75th-percentile benchmark, DOH indicates that the practice has met the reporting expectation for that measure.

This distinction matters because it gives practices starting below the established benchmark a defined path for demonstrating meaningful improvement.

You don't have to meet the goal for every reported measure.

DOH also acknowledged the growing challenge of achieving improvement on the Childhood Immunization Status measure, noting a statewide decline.

The key takeaway for practices is that they only need to achieve the applicable performance goal for one of the measures they report.

In other words, practices have flexibility in how they demonstrate performance. They can meet or exceed the established benchmark for at least one reported measure or achieve the gap-to-goal improvement target for at least one reported measure.

That makes understanding performance at the individual measure level particularly important.

What should PCMH practices be doing now?

Although performance improvement requirements extend into future payment periods, practices can begin laying the groundwork now.

Consider these four priorities:

1. Determine which quality measures apply to your practice

Reporting requirements are tied to primary specialty type, so the first step is understanding exactly which measures your practice will be expected to report.

2. Understand your current performance

Knowing where your practice stands against the established benchmarks can help identify which measures may represent the most realistic opportunities for meeting performance expectations.

3. Pay attention to the gap, not just the benchmark

If performance is below the benchmark, calculate what a gap-to-goal improvement target could look like. The DOH example demonstrates why the difference between the overall benchmark and an individual practice's improvement target can be significant.

4. Prepare for performance measurement

The April 2028 through March 2029 period adds performance improvement based on 2026 data, making today's quality data increasingly relevant to future enhanced incentive requirements.

The bottom line

The latest update gives New York state PCMH practices a clearer picture of how quality performance will factor into enhanced incentives.

Perhaps most importantly, practices don't necessarily need to reach the full 75th-percentile benchmark to demonstrate improvement. The gap-to-goal methodology provides another pathway, while practices only need to meet the applicable performance goal for one of the measures they report.

That makes the next step less about chasing every benchmark and more about understanding where your practice stands, which measures apply and where meaningful improvement is achievable.

DataGen's Enhanced PMPM 1115 Waiver PCMH Guide provides a closer look at the enhanced incentive requirements and what practices should consider as they prepare.

For additional background on the waiver, explore DataGen's New York 1115 Medicaid waiver resource.