Part 521 of Title 18 of the New York State Codes, Rules, and Regulations (NYCRR)

Details on the regulations governing Compliance Programs in New York State.

Table of Contents

Scope and Applicability Core Components of Compliance Programs Written Policies and Procedures Compliance Officer and Committee Training and Education Lines of Communication Disciplinary Policies Auditing and Monitoring Response and Prevention Additional Requirements

Part 521 of Title 18 NYCRR outlines the regulatory components for provider compliance programs in New York State. Here are the key elements:

Scope and Applicability

The regulations apply to "Required Providers," which include

Organizations subject to Articles 28 or 36 of the Public Health Law
Organizations subject to Articles 16 or 31 of the Mental Hygiene Law
Providers who receive or claim at least $1,000,000 in Medicaid revenue in a 12-month period
Medicaid Managed Care Organizations

Core Components of Compliance Programs

Required Providers must implement compliance programs with the following elements

Written Policies and Procedures

Articulate commitment to comply with federal and state standards
Describe compliance expectations and standards of conduct
Document structure and operation of the compliance program
Provide guidance on dealing with potential compliance issues
Outline disciplinary policies and non-retaliation protections

Compliance Officer and Committee

Designate a compliance officer responsible for day-to-day operations
Establish a compliance committee comprised of senior managers
Committee must meet at least quarterly and have a written charter

Training and Education

Implement annual compliance training for all "Affected Individuals"
Training must cover risk areas, policies, reporting procedures, etc.
Develop and maintain a Training Work Plan

Lines of Communication

Establish systems to receive compliance reports, including anonymous reports
Publicize reporting methods to all Affected Individuals and Medicaid recipients

Disciplinary Policies

Implement policies to encourage compliance program participation
Outline sanctions for non-compliant behavior or failure to report issues

Auditing and Monitoring

Conduct routine audits and monitoring of compliance risks
Perform annual review of compliance program effectiveness
Develop annual compliance work plan

Response and Prevention

Implement systems to investigate potential compliance problems
Respond to compliance issues and implement corrective action
Report issues to OMIG and refund overpayments as required

Additional Requirements

Conduct exclusion screening checks at least every 30 days
Retain compliance program records for at least 6 years
Submit annual compliance program certification to the Department of Health
Ensure compliance program addresses specific risk areas outlined in regulations

The regulations provide detailed expectations for each of these components to guide providers in developing and maintaining effective compliance programs. Enforcement of these updated regulations began on March 28, 2023.

____________________________

Need help? Visit www.waivergroup.com or call 302.888.9172