New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-1 - COMPLIANCE PROGRAMS › Section 521-1.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For purposes of
			   this SubPart, the terms defined in Parts 504 and 515 of this Title, except as
			   otherwise noted, shall apply.
(b)
			   In addition, for the purposes of this SubPart, the following terms have the
			   following meanings:
(1) "
Affected
			   individuals
" means all persons who are affected by the required
			   provider's risk areas including the required provider's employees, the chief
			   executive and other senior administrators, managers, contractors, agents,
			   subcontractors, independent contractors, and governing body and corporate
			   officers.
(2)
			   "
Days
" means, unless otherwise noted, calendar days.
(3) "
Effective compliance
			   program
" means a compliance program adopted and implemented by the
			   required provider that, at a minimum, satisfies the requirements of this
			   SubPart and that is designed to be compatible with the provider's
			   characteristics (i.e., size, complexity, resources, and culture), which shall
			   mean that it:
(i) is well-integrated into the
			   company's operations and supported by the highest levels of the organization,
			   including the chief executive, senior management, and the governing
			   body;
(ii) promotes adherence to
			   the required provider's legal and ethical obligations; and
(iii) is reasonably designed and implemented
			   to prevent, detect, and correct noncompliance with MA program requirements,
			   including fraud, waste, and abuse most likely to occur for the required
			   provider's risk areas and organizational experience.
(4) "
MA
" means medical
			   assistance for needy persons provided under Title 11 of Article 5 of the Social
			   Services Law.
(5) "
Managed
			   care provider
" is as defined in subdivision 1 of section 364-j  of
			   the Social Services Law.
(6)
			   "
Managed long term care plan
" or "MLTCP" means an entity that
			   has received a certificate of authority pursuant to section 4403-f  of
			   the Public Health Law to provide or arrange for health and long term care
			   services on a capitated basis for a population which the plan is authorized to
			   enroll.
(7) "
Medicaid Fraud
			   Control Unit
" or "
MFCU
" means the Attorney General of
			   the State of New York operating the program required by  42 C.F.R. Part 1007  and
			   the Social Security Act.
(8)
			   "
Office of the Medicaid Inspector General" or "OMIG
" means the
			   independent office within the department established pursuant to Title 3 of
			   Article 1 of the New York State Public Health Law.
(9) "
Organizational
			   experience
" means the required provider's:
(i) knowledge, skill, practice and
			   understanding in operating its compliance program;
(ii) identification of any issues or risk
			   areas in the course of its internal monitoring and auditing
			   activities;
(iii) experience,
			   knowledge, skill, practice and understanding of its participation in the MA
			   program and the results of any audits, investigations, or reviews it has been
			   the subject of; or
(iv) awareness
			   of any issues it should have reasonably become aware of for its category or
			   categories of service.
(10) "
Participating
			   provider
" means a provider of medical care and/or services that has a
			   provider agreement with an MMCO.
(11) "
Substantial portion of business
			   operations
" means:
(i) when a person
			   claims or has claimed, or should be reasonably expected to claim, at least one
			   million dollars ($1,000,000), in the aggregate, in any consecutive twelvemonth
			   period, directly or indirectly, from the MA program; or
(ii) when a person receives or has received,
			   or should be reasonably expected to receive, at least one million dollars
			   ($1,000,000), in the aggregate, in any consecutive twelve-month period,
			   directly or indirectly, from the MA program.