Effective Date:
Title: Section 504.1 - Policy and scope.



Section 504.1 Policy and scope. (a) The policy of this State is to make available to everyone, regardless of race, age, national origin or economic standing, uniform high quality medical care. In pursuit of this goal the department will contract with only those persons who can demonstrate that they are qualified to provide medical care, services or supplies and who can provide reasonable assurance that public funds will be properly utilized. Only qualified and responsible persons may be enrolled as providers of care, services and supplies.

(b) (1) Any person who furnishes medical care, services or supplies for which payments under the medical assistance program are to be claimed; or who arranges the furnishing of such care, services or supplies; or who submits claims for or on behalf of any person furnishing or arranging for the furnishing of such care, services or supplies must enroll as a provider of services prior to being eligible to receive such payments, to arrange for such care, services or supplies or to submit claims for such care, services or supplies.

(2) Those persons who are required to enroll as providers of services under paragraph (1) of this subdivision include, but are not limited to, laboratory directors, supervising pharmacists, nurse practitioners and physician's assistants.

(c) If a license, registration or certification is required to render the medical care, services or supplies to be furnished, an applicant must hold a proper and currently valid license, registration and/or certification to be eligible to furnish the care, services or supplies under the medical assistance program.

(d) The following definitions shall apply to this Part unless the context requires otherwise:

(1) Affiliate or affiliated person means any person having an overt, covert or conspiratorial relationship with another such that either of them may directly or indirectly control the other or such that they are under common control or ownership. For example, persons with an ownership or control interest in a provider; agents and managing employees of a provider; subcontractors; and wholly-owned suppliers of a provider with whom the provider has significant business transactions are considered affiliated with each other. Similarly, providers sharing a common owner or managing employee are affiliated with each other.

(2) Agent means a person who has actual or apparent authority to obligate or to act for another.

(3) Applicant is any person who has submitted an application for enrollment.

(4) Application for enrollment or application means any document submitted by a person for the purpose of enrolling in the medical assistance program.

(5) Conviction or convicted means that a plea of guilty or no contest or a verdict of guilty has been entered in a Federal, State or local court, regardless of whether an appeal from the judgment is pending or whether a certificate of relief from civil disability has been granted.

(6) Department means the State Department of Social Services, or a local social services department where enrollment of specified provider types has been delegated to or retained by such local district (e.g., in the case of certain transportation providers).

(7) Enrollment or enrolling is the process by which an applicant contracts with the department to participate in the medical assistance program as a provider of medical care, services or supplies.

(8) Furnishes means the provision of medical care, services or supplies, either directly or indirectly by supervising the provision of medical care, services or supplies or by prescribing or ordering care, services or supplies.

(9) Indirect ownership interest means an ownership interest in an entity that has an ownership interest in a provider. This term includes an ownership interest in any entity that has an indirect ownership interest in a provider.

(10) Indictment means an indictment has been handed down by a grand jury, or an accusatory instrument charging a crime which would be a felony under New York State law has been filed.

(11) Managing employee means a general manager, business manager, administrator, director, or other person who exercises operational or managerial control of a provider, or who directly or indirectly conducts the day-to-day operation of a provider.

(12) Medicaid is the program of State-administered medical assistance established by title XIX of the Social Security Act.

(13) Medical assistance program or program means the program of medical assistance for needy persons provided for in title 11 of article 5 of the Social Services Law.

(14) Medicare is the program of hospital and medical insurance established under title XVIII of the Social Security Act.

(15) Ownership interest means possession of equity in the capital, the stock or the profits of a provider.

(16) Participation is the ability and authority to furnish care, services or supplies to eligible recipients and to receive payment from the medical assistance program for such care, services or supplies.

(17) Person includes natural persons, corporations, partnerships, associations, clinics, groups and other entities.

(18) Person with an ownership or control interest means a person who:

(i) has an ownership interest totaling five percent or more in a provider;

(ii) has an indirect ownership interest equal to five percent or more in a provider;

(iii) has a combined direct and indirect ownership interest equal to five percent or more in a provider;

(iv) owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the provider if that interest equals at least five percent of the value of the property or assets of the provider;

(v) is an officer or director of a provider that is organized as a corporation;

(vi) is a partner in a provider that is organized as a partnership.

(19) Provider is any person who has enrolled under the medical assistance program to furnish medical care, services or supplies; or to arrange for the furnishing of such care, services or supplies; or to submit claims for such care, services or supplies for or on behalf of another person. Only a provider may order or prescribe care, services or supplies, exclusive of in-patient hospital care, if such ordering or prescribing results in payment of more than 4,500 claims totaling $75,000 or more per year. The failure or refusal of a person who orders or prescribes such amounts to enroll as a provider in the medical assistance program will result in the denial of payment by the department for care, services or supplies ordered or prescribed by such person following such failure or refusal. For the purposes of this paragraph, "claim" has the same meaning as set forth in section 515.1(b)(3) of this Title.

(20) Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 or five percent of a provider's total operating expenses.

(21) Subcontractor means any person to which a provider has contracted or delegated some of its management functions, or its responsibilities for providing medical care, services or supplies; or its claiming or claims preparation or processing functions or responsibilities.

(22) Supplier means a person from whom a provider purchases goods and services used in carrying out its responsibilities under the medical assistance program (e.g., a service bureau, or billing service, a commercial laundry, a manufacturer, or a pharmaceutical firm).

(23) Wholly owned supplier means a supplier whose total ownership interest is held by a provider or a person with an ownership or control interest in a provider.

(24) Service bureau means any person who provides claims processing or claims submission services for or on behalf of a provider, including a business agent, billing service or accounting firm.

(25) Laboratory director means an individual who has met the quali
fications of a laboratory director as set forth in 10 NYCRR 19.2 and who has those responsibilities set forth in 10 NYCRR 58-1.2.

(26) Supervising pharmacist means the individual designated by a pharmacy on the pharmacy's State registration form as the licensed pharmacist having personal supervision of the pharmacy.

(27) Nurse practitioner means an individual who is licensed and currently registered as a professional nurse in the State and who is certified under section 6910 of the Education Law as a nurse practitioner.

(28) Physician's assistant means a person who is registered as a physician's assistant pursuant to section 6541 of the Education Law.


Volume: C