To ensure integrity of the New York State Medicaid program, the Office of Medicaid Inspector General (OMIG) is responsible for ensuring that funds are spent properly while remaining in compliance with all relevant laws. New York State’s compliance program requirements, particularly for Medicaid providers, involve seven key elements:

1. Written policies, procedures, and standards of conduct
2. Compliance officers and compliance committees
3. Compliance program training and education
4. Lines of communication
5. Disciplinary standards
6. Auditing and monitoring
7. Prompt response to compliance issues

Implementation of these elements within Medicaid providers’ compliance programs is crucial for preventing fraud, waste, and abuse within the Medicaid program.

Medicaid providers that adopt, implement, and maintain a strong and effective compliance program are essential to detecting and correcting payment and billing errors and identifying potential fraud. Required providers, as defined by OMIG and explained below, help identify and prevent errors and fraudulent activity within the Medicaid program and, in turn, protect Medicaid Members.

Under NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and Regulations (18 NYCRR) SubPart 521-1, if your organization answers YES to any of the following questions, you are required to have a compliance program in New York State. These questions can also be found on the OMIG website at https://omig.ny.gov/compliance/compliance.

1. Is your organization subject to Article 28 or Article 36 of the NYS Public Health Law (PBH)?
2. Is your organization subject to Article 16 or Article 31 of the NYS Mental Hygiene Law?
3. Notwithstanding the provisions of § 4414 of the NYS PBH, is your organization a managed care provider, as defined in SOS § 364-j, which includes managed long-term care plans?
4. Does your organization claim — and/or can be reasonably expected to claim —Medicaid services or supplies of at least $1,000,000 in any consecutive 12-month period?
5. Does your organization receive Medicaid payments — and/or can be reasonably expected to receive payments — either directly or indirectly, of at least $1,000,000 in any consecutive 12-month period?  Indirect Medicaid reimbursement is any payment that you receive for the delivery of Medicaid care, services, or supplies that comes from a source other than the State of New York.  For example, if you provide covered services to a Medicaid beneficiary who is enrolled in a Medicaid Managed Care Plan, the payment you receive from the Managed Care Organization is considered an indirect payment.

Payments to organizations from Care Compass to provide services in the Social Impact Pilot Program (SIPP) and/or the Social Care Network (SCN) are considered indirect Medicaid reimbursements. The actual and/or anticipated funding amounts from these indirect payments should be included when an organization calculates whether it meets the $1,000,000 threshold of receipt of Medicaid payments in any consecutive 12-month period.

Please contact Care Compass with questions regarding funds you have or are contracted with Care Compass to receive from other programs to determine whether they are considered indirect Medicaid payments.

Additional Resources: The Office of the Medicaid Inspector General (OMIG) has posted comprehensive guidance related to provider compliance programs on its website:

Provider Compliance Programs
Compliance Program Review Module
Compliance Program Self-Assessment Form
Compliance Program Requirements Frequently Asked Questions