Chapter 35: Regulatory Mandatory Reporting

Federal, state and city agencies, including the New York State Department of Health and the New York City Department of Health and Mental Hygiene, enact laws obligating practitioners to track conditions that affect public health and ensure public safety. This chapter outlines the government reporting procedures EmblemHealth practitioners are required to follow.

New York State requires regular reporting on issues ranging from diseases to medical research. For more information, visit the New York State Department of Health (NYSDOH) website at www.health.ny.gov and search for "Rules, Regulations and Laws."

Communicable Diseases

Physicians are required to report communicable diseases, including cases, suspected cases and certain carriers, to local public health agencies (LPHAs). This includes sexually transmitted diseases (STDs), tuberculosis, and COVID-19. For mandatory physician reporting of patient information, visit the NYSDOH website at www.health.ny.gov aand search for "Infection Control Reporting Requirements."

For Medicaid/HARP/CHPlus members, EmblemHealth and our participating practitioners are required to provide data exchange services to support the Citywide Immunization Registry (CIR) and Lead Poisoning Prevention Program (LPPP).

New York City Resources

The Compendium of Public Health Requirements and Recommendations: For Health Care Providers Working with Managed Care Organizations, published by the New York City Department of Health and Mental Hygiene (NYCDOHMH), contains public health requirements focusing on two areas:

• Reporting requirements for communicable diseases and injuries, immunizations, lead test results, termination of pregnancy, and school health
• Guidelines for prevention, diagnosis and management on the following topics: communicable diseases, immunizations, emergency preparedness, child development, breast-feeding, child safety, adolescent health, domestic violence, reproductive health, oral health, chronic diseases, and chronic health problems

For additional guidelines and information, visit www.nyc.gov.

EmblemHealth network practitioners may need to report to one or more of the following agencies:

• Centers for Disease Control and Prevention 
• Centers for Medicare & Medicaid Services
• Food and Drug Administration 
• New York City Department of Health and Mental Hygiene 
• New York State Cancer Registry 
• New York State Central Register of Child Abuse and Maltreatment
• New York State Department of Health 
• New York State Immunization Information System 
• New York State Justice Center
• New York State Office of Mental Health
• New York State Penal Code
• New York State Pesticide Poisoning Registry
• New York State Rules and Regulations on Controlled Substances – Public Health Law
• NYCDOHMH Citywide Immunization Registry 
• NYCDOHMH Lead Poisoning Prevention Program 
• NYSDOH Alzheimer's Disease and other Dementias Registry
• NYSDOH Bureau of Communicable Disease Control
• NYSDOH Bureau of Occupational Health – Occupational Lung Disease Registry
• NYSDOH Center for Environmental Health
• NYSDOH Congenital Malformations Registry
• NYSDOH Division of Quality and Surveillance for Nursing Homes and ICFs/MR 
• NYSDOH Hospital Complaints
• NYSDOH Office of Professional Medical Conduct

New York State law requires home care organizations to comply with minimum wage requirements specified in Public Health Law §3614-c — Home Care Worker Wage Parity. The law applies to the following home health agencies seeing our Medicaid, CHPlus, and/or HARP members in New York City, Nassau, Suffolk, and/or Westchester counties:

• Consumer Directed Personal Assistance Program Fiscal Intermediaries (FIs)
• Licensed Home Care Services Agencies (LHCSAs)
• Certified Home Health Agencies (CHHAs)
  

For guidance on wage parity compliance — including certification requirements, employer statements, reporting requirements, and penalties for non-compliance — visit the New York State Department of Health website.

Compliance Requirements Update
The New York State Department of Health (NYSDOH) recently issued updated guidance on wage parity compliance and certification submission dates for 2023.

JP#62404 12/2023

The New York State Department of Health requires written disclosure regarding ownership, control, and criminal convictions related to certain controlling persons’ involvement in Medicare, Medicaid, or Title XX programs. Specifically: 

• Section 42 CRF455.104 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect the disclosure of complete ownership, control, and relationship information from certain entities identified in the statute. These include: 
  •  all participating hospitals 
  • skilled nursing facilities 
  • home health agencies 
  • independent clinical laboratories 
  • renal disease facilities, and 
  • any entity (other than an individual practitioner or group of practitioners) that furnishes or arranges for health-related services for which it provides claims payment under any plan or program established under Title V or Title XX of the Social Security Act 
    
• Section 42 CRF455.106 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect and report health care-related criminal conviction disclosure information (initially and upon renewal of their contracts) of any managing employee who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or a Title XX program

Disclosure forms must be completed and submitted as part of the credentialing and recredentialing processes. This applies to both directly contracted providers and delegated entities. Disclosure forms must also be submitted when a reportable event occurs and upon request of the New York State Department of Health and EmblemHealth. 

Required annual compliance certification on Office of the Medicaid Inspector General’s website 
If you are a Medicaid provider, you are likely required to attest each December you have developed and implemented a compliance program to detect and prevent fraud, waste, and abuse in the Medicaid program. Depending on the type of provider you are, or the extent to which you treat Medicaid members, you may be required to complete one or both Office of the Medicaid Inspector General (OMIG) Annual Compliance Certifications. The certifications may only be done by completing the certification form available on OMIG’s website (omig.ny.gov/compliance/compliance-certification) and clicking on the appropriate certification button (“SSL Certification” or “DRA Certification”). One attestation is needed for each Federal Employer Identification Number (FEIN) or Social Security number (SSN) used to receive Medicaid payments. You do not need to submit a copy of the compliance plan or self-assessment of your plan. With regard to the Social Services Law (SSL) certification, New York State’s (NYS’s) mandatory compliance program law applies to Medicaid providers subject to Public Health Law (PHL) Articles 28 or 36, or Mental Hygiene Law (MHL) Articles 16 or 31, regardless of the amount they bill, order, or receive from NYS’s Medicaid program. Plans will need to monitor network provider compliance with the SSL certification requirement. 

In addition, a compliance program is required for other persons, providers, or affiliates who provide care, services, or supplies under the Medicaid program, or who submit claims for care, services, or supplies for or on behalf of another person for which Medicaid is, or should be reasonably expected by the provider to be, a substantial portion of their business operations as follows: 

• A person, provider, or affiliate who claims, orders, has claimed or ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from Medicaid; 
  
• A person, provider, or affiliate who receives, has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from Medicaid or a Medicaid Managed Care Plan; or 
  
• A person, provider, or affiliate who submits or has submitted claims for care, services, or supplies to the Medicaid program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period. 
  

The law and regulations contain a set of eight minimum core elements applicable to all providers, regardless of size. However, the law also recognizes compliance programs should reflect the provider’s size, complexity, resources, and culture as long as the compliance program meets the requirements. The second annual compliance attestation, referred to as the Deficit Reduction Act (DRA) certification, must be completed by health care entities who receive or make $5 million or more in Medicaid payments. Providers required to meet both provisions usually include the DRA requirements in their (typically more comprehensive) mandatory compliance programs. OMIG suggests Medicaid providers review OMIG’s published Compliance Guidance, Medicaid Updates, and Compliance Alerts, among other OMIG publications and outreach methods, for information on how to meet NYS mandatory compliance program requirements. There is a Compliance Library on OMIG’s website to guide providers in developing and implementing an effective compliance program. Medicaid providers are encouraged to subscribe to OMIG’s listserv. The listserv provides an email notification of any changes to OMIG’s website, including changes to published compliance program-related materials. To see more detail on the compliance program requirements, see: omig.ny.gov/sites/default/files/document/sslfaqs-final.pdf and omig.ny.gov/sites/default/files/document/DRAFAQsfinal.pdf.