N.Y. Comp. Codes R. & Regs. tit. 18 § 521-1.2

Current through Register Vol. 46, No. 25, June 18, 2024

Section 521-1.2 - Definitions

(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.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 521-1.2

Adopted New York State Register December 28, 2022/Volume XLIV, Issue 52, eff. 12/28/2022