New York State Patient-Centered Medical Home (NYS PCMH) Recognition Program

NCQA, the creator of the nation’s leading patient-centered medical home (PCMH) program, collaborated with the New York State Department of Health (NYSDOH) to develop a customized PCMH recognition program. NYS PCMH supports the state’s initiative to improve primary care through the medical home model. It also promotes the Triple Aim: better health, lower costs and better patient experience.

What Is PCMH?

PCMH is a care delivery model where the primary care team, along with the patient (and family, when appropriate), are responsible for managing the full spectrum of health care needs. The team also coordinates with clinicians in other settings when care cannot be provided in the primary care setting.


The PCMH model focuses on care coordination, population health, evidence-based guidelines and effective use of HIT to meet patients’ needs. NYS PCMH recognition helps practices put the structure, systems and processes in place to be effective medical homes.

The NYS PCMH model helps practices:

  • Improve patient-centered access and patient experience.
  • Perform comprehensive health assessments to identify patient needs.
  • Deliver better preventive care such as immunizations and cancer screenings.
  • Prioritize comprehensive care management to keep chronic conditions under control.
  • Coordinate with other clinicians involved in patient care and close referral loops to improve continuity and avoid gaps.
  • Identify patients who require recommended interventions and patients who need medication monitoring.

NYS PCMH Program Overview

The NYS PCMH recognition program features 6 concepts that make up a medical home. Criteria are the basis for these concepts. They are the activities for which a practice must demonstrate satisfactory performance to earn NYS PCMH Recognition. Criteria were developed from evidence-based guidelines and best practices.

To earn NYS PCMH Recognition, a practice must meet all 40 core criteria and 11 NYS required criteria ( with elective credit). Practices must earn a total of 25 credits in elective criteria across 5 of 6 concepts, (15-17 credits are earned by the required NYS criteria, crossing 5 of 6 concepts. Practices decide which of the remaining 8-10 credits of elective criteria to complete.

The NYS PCMH Standards and Guidelines document details program requirements.

How to Enroll in NYS PCMH

A practice downloads the Standards and Guidelines document, which contains the requirements for the program. The entire recognition process is managed through Quality Performance Assessment Support System (Q-PASS), a user-friendly, online platform that allows for the upload of documentation, tracking of progress and management of practice sites and clinicians.
Paths to enroll for practices.

NOTE: NCQA Specific Policy for NYSPCMH and Virtual Care.

Practices that select 100% virtual in Q-PASS are not eligible to come through NYS PCMH and cannot receive Medicaid enhanced reimbursement.  If you have questions about this policy, please email

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