NY State Senate Bill 2025-S4955A

Senate Bill S4955A

2025-2026 Legislative Session

Relates to the functions of the Medicaid inspector general with respect to audit and review of medical assistance program funds

download bill text pdf

Current Bill Status - In Senate Committee Health Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Mar 04, 2025	print number 4955a
Mar 04, 2025	amend (t) and recommit to health
Feb 14, 2025	referred to health

Bill Amendments

Original

A (Active)

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2025-S4955 - Details

See Assembly Version of this Bill:: A1069
Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §§30-a & 35, add §37, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2021-2022: S4486
2023-2024: S5329, A6813

2025-S4955 - Summary

Requires the Medicaid inspector general to comply with standards relating to the audit and review of medical assistance program funds.

2025-S4955 - Sponsor Memo

                                 
BILL NUMBER: S4955

SPONSOR: HARCKHAM
 
TITLE OF BILL:

An act to amend the public health law and the social services law, in
relation to the functions of the Medicaid inspector general with respect
to audit and review of medical assistance program funds and requiring
notice of certain investigations

 
PURPOSE OR GENERAL IDEA OF BILL:

To provide due process protections to health care providers and recipi-
ents in the medical assistance program when under scrutiny by the Office
of the Medicaid Inspector General (OMIG).

 
SUMMARY OF PROVISIONS:

Section 1 amends Public Health Law § 30,-a by adding new subdivisions,
which defines various terms including "abuse", "creditable allegations
of fraud", "fraud"," medical assistance", "overpayment" and " provider".

§ 2 amends Public Health Law § 32 subdivision 20 to make clear that the
Office of the Medicaid Inspector General (OMIG) must act consistently
with all applicable state and federal laws, regulations, policies,
guidelines, and standards.

§ 3 adds two new sections to the Public Health Law, § 37 and § 38. § 37
addresses audit and recovery of medical assistance to providers. § 38
addresses procedures, practices and standards for recipients.

§ 4 amends Social Services Law § 363-d (3) (c) to require OMIG to notify
a provider if the provider's compliance program is not satisfactory, and
to allow the provider 60 days to submit a proposal for a satisfactory
compliance program. It also adds a new subdivision 8 to the section to
require OMIG regulations, determinations, or findings relating to a
compliance program to be consistent with subdivision 3.

§ 5 adds a new subsection 6-b to Public Health Law § 32, requiring OMIG
to consult with the Commissioner of Health on preparing and filing an
annual report by the Commissioner on the impacts that all civil and
administrative enforcement actions taken in the previous year have had
and will have on the quality and availability of medical care and
services, the best interests of the medical assistance program and its
recipients, and the fiscal solvency of the providers subject to these
actions.

§ 6 is the effective date which is thirty days after enactment.

 
JUSTIFICATION:

When the OMIG was created in 2007, the emphasis of the legislature and
the concern of the public was on fraud and waste in the Medicaid system.
Experience, with the law has made it clear that the current statute is
missing key provisions necessary to assure fairness and procedural clar-
ity for all the parties involved, including the personnel of the OMIG.

OMIG audits that punish providers for technical errors- not fraud- do
not help anyone in the Medicaid system, especially when those errors are
the result of contradictory guidance provided by different state agen-
cies. OMIG's practice of extrapolating millions of dollars of claims
from a small sample of technical errors has been forcing already
stretched-thin health care providers (especially in the behavioral
health system) to close, which ultimately harms patients.  New York's
patients cannot afford to lose any more behavioral health providers,
especially over unintentional administrative errors.

This bill addresses due process for Medicaid beneficiaries who deserve
advance notice of any investigations and details about what exactly is
being investigated. These beneficiaries deserve to know their rights
before OMIG makes any recoveries or enforcement actions against them.
These common-sense requirements are necessary to protect vulnerable New
Yorkers from OMIG actions that adversely impact the provision of
services to vulnerable New Yorkers.

 
PRIOR LEGISLATIVE HISTORY:

2023-2024: S5329E/A6813 - Passed Senate/Died in Ways & Means

2021-2022: S4486B/A7889A - Vetoed Memo. 89

2024: Amended Sec. 1 Part 8 to reference federal law

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
This act shall take effect on January 1, 2028.

2025-S4955 - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4955
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 14, 2025
                                ___________
 
 Introduced by Sens. HARCKHAM, BORRELLO, FERNANDEZ, GALLIVAN, MAY, MAYER,
   ROLISON,  SEPULVEDA,  WEBB -- read twice and ordered printed, and when
   printed to be committed to the Committee on Health
 
 AN ACT to amend the public health law and the social  services  law,  in
   relation  to  the  functions  of  the  Medicaid inspector general with
   respect to audit and review of medical assistance  program  funds  and
   requiring notice of certain investigations
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 30-a of the public health law, as added by  chapter
 442 of the laws of 2006, is amended to read as follows:
   §  30-a.  Definitions.  For  the purposes of this title, the following
 definitions shall apply:
   1. "ABUSE" MEANS PROVIDER PRACTICES THAT ARE INCONSISTENT  WITH  SOUND
 FISCAL, BUSINESS OR MEDICAL PRACTICES, AND RESULT IN AN UNNECESSARY COST
 TO  THE  MEDICAID PROGRAM, OR IN REIMBURSEMENT FOR SERVICES THAT ARE NOT
 MEDICALLY NECESSARY OR THAT FAIL TO MEET PROFESSIONALLY RECOGNIZED STAN-
 DARDS FOR HEALTH CARE.  IT  ALSO  INCLUDES  BENEFICIARY  PRACTICES  THAT
 RESULT IN UNNECESSARY COST TO THE MEDICAID PROGRAM.
   2.  "CREDITABLE ALLEGATION OF FRAUD" (A) MEANS AN ALLEGATION WHICH HAS
 BEEN VERIFIED BY THE INSPECTOR,  FROM  ANY  SOURCE,  INCLUDING  BUT  NOT
 LIMITED TO THE FOLLOWING:
   I. FRAUD HOTLINES TIPS VERIFIED BY FURTHER EVIDENCE;
   II. CLAIMS DATA MINING; AND
   III.  PATTERNS  IDENTIFIED THROUGH PROVIDER AUDITS, CIVIL FALSE CLAIMS
 CASES, AND LAW ENFORCEMENT INVESTIGATIONS.
   (B) ALLEGATIONS ARE CONSIDERED TO BE CREDIBLE WHEN THEY HAVE AN  INDI-
 CIA OF RELIABILITY AND THE INSPECTOR HAS REVIEWED ALL ALLEGATIONS, FACTS
 AND EVIDENCE CAREFULLY AND ACTS JUDICIOUSLY ON A CASE-BY-CASE BASIS.
   3. "FRAUD" MEANS AN INTENTIONAL DECEPTION OR MISREPRESENTATION MADE BY
 A  PERSON  WITH  THE  KNOWLEDGE  THAT THE DECEPTION OR MISREPRESENTATION
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD02919-01-5

 S. 4955                             2
 
 COULD RESULT IN SOME UNAUTHORIZED BENEFIT TO THE PERSON  OR  SOME  OTHER
 PERSON.    IT  INCLUDES  ANY ACT THAT CONSTITUTES FRAUD UNDER APPLICABLE
 FEDERAL OR STATE LAW.
   4.  "Inspector"  means  the Medicaid inspector general created by this
 title.
   [2.] 5. "Investigation" means investigations of fraud, abuse, or ille-
 gal acts perpetrated within the medical assistance program, by providers
 or recipients of medical assistance care, services and supplies.
   6. "MEDICAL ASSISTANCE," "MEDICAID," AND "RECIPIENT"  SHALL  HAVE  THE
 SAME  MEANING  AS  THOSE  TERMS  IN  TITLE ELEVEN OF ARTICLE FIVE OF THE
 SOCIAL SERVICES LAW AND SHALL INCLUDE ANY PAYMENTS  TO  PROVIDERS  UNDER
 ANY MEDICAID MANAGED CARE PROGRAM.
   [3.]  7.  "Office"  means the office of the Medicaid inspector general
 created by this title.
   8. "OVERPAYMENT" MEANS ANY FUNDS THAT A PROVIDER RECEIVES OR  RETAINS,
 TO  WHICH THE PROVIDER IS NOT, AFTER APPLICABLE RECONCILIATION, ENTITLED
 UNDER THE MEDICAL ASSISTANCE PROGRAM.
   9. "PROVIDER" MEANS ANY PERSON OR ENTITY ENROLLED AS A PROVIDER IN THE
 MEDICAL ASSISTANCE PROGRAM.
   § 2. Subdivision 20 of section 32 of the public health law,  as  added
 by chapter 442 of the laws of 2006, is amended to read as follows:
   20.  to,  consistent  with  [provisions  of] this title AND APPLICABLE
 FEDERAL LAWS, REGULATIONS, POLICIES, GUIDELINES AND STANDARDS, implement
 and amend, as needed, rules and regulations relating to the  prevention,
 detection,  investigation  and  referral  of  fraud and abuse within the
 medical assistance program  and  the  recovery  of  improperly  expended
 medical assistance program funds;
   §  3.  The  public health law is amended by adding two new sections 37
 and 38 to read as follows:
   § 37. AUDIT AND RECOVERY OF MEDICAL ASSISTANCE PAYMENTS TO  PROVIDERS.
 ANY  AUDIT  OR  REVIEW  OF ANY PROVIDER CONTRACTS, COST REPORTS, CLAIMS,
 BILLS, OR MEDICAL ASSISTANCE PAYMENTS BY THE  INSPECTOR,  ANYONE  DESIG-
 NATED  BY THE INSPECTOR OR OTHERWISE LAWFULLY AUTHORIZED TO CONDUCT SUCH
 AUDIT OR REVIEW, OR ANY OTHER AGENCY WITH JURISDICTION TO  CONDUCT  SUCH
 AUDIT OR REVIEW, SHALL COMPLY WITH THE FOLLOWING STANDARDS:
   1.  RECOVERY  OF ANY OVERPAYMENT RESULTING FROM ANY AUDIT OR REVIEW OF
 PROVIDER CONTRACTS, COST REPORTS, CLAIMS, BILLS, OR  MEDICAL  ASSISTANCE
 PAYMENTS  SHALL  NOT  COMMENCE PRIOR TO SIXTY DAYS AFTER DELIVERY TO THE
 PROVIDER OF A FINAL AUDIT REPORT OR FINAL NOTICE OF  AGENCY  ACTION,  OR
 WHERE  THE  PROVIDER  REQUESTS  A HEARING OR APPEAL WITHIN SIXTY DAYS OF
 DELIVERY OF THE FINAL AUDIT REPORT OR FINAL  NOTICE  OF  AGENCY  ACTION,
 UNTIL A FINAL DETERMINATION OF SUCH HEARING OR APPEAL IS MADE.
   2.  PROVIDER CONTRACTS, COST REPORTS, CLAIMS, BILLS OR MEDICAL ASSIST-
 ANCE PAYMENTS THAT WERE THE SUBJECT MATTER OF A PREVIOUS AUDIT OR REVIEW
 WITHIN THE LAST THREE YEARS SHALL NOT BE  SUBJECT  TO  REVIEW  OR  AUDIT
 AGAIN  EXCEPT ON THE BASIS OF NEW INFORMATION, FOR GOOD CAUSE TO BELIEVE
 THAT THE PREVIOUS REVIEW OR AUDIT WAS ERRONEOUS, OR WHERE THE  SCOPE  OF
 THE  INSPECTOR'S  REVIEW  OR  AUDIT  IS SIGNIFICANTLY DIFFERENT FROM THE
 SCOPE OF THE PREVIOUS REVIEW OR AUDIT.
   3. ANY REVIEWS OR AUDITS OF PROVIDER CONTRACTS, COST REPORTS,  CLAIMS,
 BILLS  OR  MEDICAL ASSISTANCE PAYMENTS SHALL APPLY THE STATE LAWS, REGU-
 LATIONS AND THE APPLICABLE, DULY PROMULGATED POLICIES, GUIDELINES, STAN-
 DARDS, PROTOCOLS AND INTERPRETATIONS OF STATE AGENCIES WITH JURISDICTION
 AND IN EFFECT AT THE TIME THE PROVIDER ENGAGED IN THE  APPLICABLE  REGU-
 LATED  CONDUCT OR PROVISION OF SERVICES.  FOR THE PURPOSE OF THIS SUBDI-
 VISION, THE STATE LAW, REGULATION OR THE APPLICABLE  PROMULGATED  AGENCY
 S. 4955                             3
 
 POLICY,  GUIDELINE,  STANDARD,  PROTOCOL  OR INTERPRETATION SHALL NOT BE
 DEEMED IN EFFECT IF FEDERAL GOVERNMENTAL APPROVAL IS PENDING OR  DENIED.
 THE  INSPECTOR  SHALL  PUBLISH PROTOCOLS APPLICABLE TO AND GOVERNING ANY
 AUDIT  OR  REVIEW  OF  A   PROVIDER OR PROVIDER CONTRACTS, COST REPORTS,
 CLAIMS, BILLS OR MEDICAL ASSISTANCE PAYMENTS ON THE OFFICE  OF  MEDICAID
 INSPECTOR GENERAL WEBSITE.
   4.  (A) IN THE EVENT OF ANY OVERPAYMENT BASED UPON A PROVIDER'S ADMIN-
 ISTRATIVE OR TECHNICAL ERROR, THE PROVIDER  SHALL  HAVE  THE  LONGER  OF
 SIXTY  DAYS  FROM  NOTICE  OF  THE MISTAKE OR SIX YEARS FROM THE DATE OF
 SERVICE TO SUBMIT A CORRECTED CLAIM PROVIDED (I) THE ERROR WAS A GENUINE
 ERROR WITHOUT INTENT TO FALSIFY OR DEFRAUD, (II) THE PROVIDER MAINTAINED
 CONTEMPORANEOUS DOCUMENTATION TO SUBSTANTIATE THE CORRECT CLAIMS  INFOR-
 MATION,  (III)  SUCH ERROR IS THE SOLE BASIS FOR THE FINDING OF AN OVER-
 PAYMENT, AND (IV) THERE IS NO FINDING OF ANY OVERPAYMENT FOR SUCH  ERROR
 BY A FEDERAL AGENCY OR OFFICIAL.
   (B) NO OVERPAYMENT SHALL BE CALCULATED FOR ANY ADMINISTRATIVE OR TECH-
 NICAL ERROR CORRECTED AS REQUIRED IN PARAGRAPH (A) OF THIS SUBDIVISION.
   (C)  "ADMINISTRATIVE  OR TECHNICAL ERROR" SHALL INCLUDE ANY ERROR THAT
 CONSTITUTES EITHER A (I) MINOR ERROR OR OMISSION OR  (II)CLERICAL  ERROR
 OR OMISSION UNDER THE MEDICARE MODERNIZATION ACT OR CENTERS FOR MEDICAID
 AND  MEDICAID  SERVICE REGULATIONS, AND SHALL INCLUDE HUMAN AND CLERICAL
 ERRORS THAT RESULT IN ERRORS AS TO FORM OR CONTENT OF A CLAIM.
   5. (A) IN DETERMINING THE AMOUNT OF ANY OVERPAYMENT TO A PROVIDER, THE
 INSPECTOR SHALL  UTILIZE SAMPLING AND EXTRAPOLATION CONSISTENT  WITH THE
 CENTERS FOR MEDICARE AND MEDICAID SERVICES POLICIES AS DESCRIBED IN  THE
 CENTERS FOR MEDICARE AND MEDICAID PROGRAM INTEGRITY MANUAL.
   (B)  THE  FINAL  AUDIT  REPORT  OR FINAL NOTICE OF AGENCY ACTION SHALL
 INCLUDE A STATEMENT OF THE SPECIFIC FACTUAL AND LEGAL BASIS FOR  UTILIZ-
 ING  EXTRAPOLATION AND THE INAPPROPRIATE USE OF EXTRAPOLATION SHALL BE A
 BASIS FOR APPEAL. THIS SUBDIVISION SHALL NOT BE CONSTRUED TO  LIMIT  THE
 RECOUPMENT  OF  AN  OVERPAYMENT  IDENTIFIED  WITHOUT THE USE OF EXTRAPO-
 LATION.
   (C) IF THE PROVIDER HAS WAIVED ITS RIGHT TO A HEARING, OR IF A PROVID-
 ER REQUESTS A HEARING, UNTIL THE HEARING DETERMINATION  IS  ISSUED,  THE
 PROVIDER  SHALL  HAVE  THE  RIGHT TO PAY THE LOWER CONFIDENCE LIMIT PLUS
 APPLICABLE INTEREST IN FULFILLMENT OF  THIS  PARAGRAPH,  THE  APPLICABLE
 LOWER  CONFIDENCE  LIMIT  SHALL  BE  CALCULATED USING AT LEAST A  NINETY
 PERCENT CONFIDENCE LEVEL.
   6. (A) THE PROVIDER SHALL BE PROVIDED AS PART OF THE DRAFT AUDIT FIND-
 INGS  A  DETAILED  WRITTEN  EXPLANATION  OF  THE  EXTRAPOLATION   METHOD
 EMPLOYED,  INCLUDING  THE  SIZE OF THE SAMPLE, THE SAMPLING METHODOLOGY,
 THE DEFINED UNIVERSE OF CLAIMS, THE  SPECIFIC  CLAIMS  INCLUDED  IN  THE
 SAMPLE,  THE RESULTS OF THE SAMPLE, THE ASSUMPTIONS MADE ABOUT THE ACCU-
 RACY AND RELIABILITY OF THE SAMPLE AND THE LEVEL OF  CONFIDENCE  IN  THE
 SAMPLE  RESULTS,  AND  THE  STEPS UNDERTAKEN AND STATISTICAL METHODOLOGY
 UTILIZED TO CALCULATE THE ALLEGED OVERPAYMENT AND ANY APPLICABLE  OFFSET
 BASED  ON  THE  SAMPLE RESULTS. THIS WRITTEN INFORMATION SHALL INCLUDE A
 DESCRIPTION OF THE SAMPLING AND EXTRAPOLATION METHODOLOGY.
   (B) THE SAMPLING  AND  EXTRAPOLATION  METHODOLOGIES  UTILIZED  BY  THE
 INSPECTOR  SHALL BE CONSISTENT WITH ACCEPTED STANDARDS OF SOUND AUDITING
 PRACTICE AND STATISTICAL ANALYSIS.
   7. THE REQUIREMENTS OF THIS SECTION SHALL  BE  INTERPRETED  CONSISTENT
 WITH  AND  SUBJECT TO ANY APPLICABLE FEDERAL LAW, RULES AND REGULATIONS,
 OR BINDING FEDERAL AGENCY GUIDANCE AND DIRECTIVES.  THE  REQUIREMENTS OF
 THIS SECTION SHALL NOT APPLY TO ANY INVESTIGATION BY THE INSPECTOR WHERE
 THERE IS CREDIBLE ALLEGATIONS OF FRAUD OR WHERE THERE IS A FINDING  THAT
 S. 4955                             4
 
 THE  PROVIDER  HAS ENGAGED IN DELIBERATE ABUSE OF THE MEDICAL ASSISTANCE
 PROGRAM.
   §  38.  PROCEDURES,  PRACTICES  AND  STANDARDS FOR RECIPIENTS. 1. THIS
 SECTION APPLIES TO ANY ADJUSTMENT OR RECOVERY OF  A  MEDICAL  ASSISTANCE
 PAYMENT  FROM  A  RECIPIENT,  AND  ANY INVESTIGATION OR OTHER PROCEEDING
 RELATING THERETO.
   2. AT LEAST FIVE BUSINESS DAYS PRIOR TO COMMENCEMENT OF ANY  INTERVIEW
 WITH  A  RECIPIENT  AS  PART OF AN INVESTIGATION, THE INSPECTOR OR OTHER
 INVESTIGATING ENTITY SHALL PROVIDE THE RECIPIENT WITH WRITTEN NOTICE  OF
 THE  INVESTIGATION.  THE NOTICE OF THE INVESTIGATION SHALL SET FORTH THE
 BASIS FOR THE INVESTIGATION; THE POTENTIAL  FOR  REFERRAL  FOR  CRIMINAL
 INVESTIGATION;  THE  INDIVIDUAL'S RIGHT TO BE ACCOMPANIED BY A RELATIVE,
 FRIEND, ADVOCATE OR ATTORNEY DURING QUESTIONING; CONTACT INFORMATION FOR
 LOCAL LEGAL SERVICES OFFICES; THE INDIVIDUAL'S RIGHT TO  DECLINE  TO  BE
 INTERVIEWED OR PARTICIPATE IN AN INTERVIEW BUT TERMINATE THE QUESTIONING
 AT ANY TIME WITHOUT LOSS OF BENEFITS; AND THE RIGHT TO A FAIR HEARING IN
 THE EVENT THAT THE INVESTIGATION RESULTS IN A DETERMINATION OF INCORRECT
 PAYMENT.
   3.  FOLLOWING COMPLETION OF THE INVESTIGATION AND AT LEAST THIRTY DAYS
 PRIOR TO COMMENCING A RECOVERY OR ADJUSTMENT ACTION OR REQUESTING VOLUN-
 TARY REPAYMENT,  THE  INSPECTOR  OR  OTHER  INVESTIGATING  ENTITY  SHALL
 PROVIDE THE RECIPIENT WITH WRITTEN NOTICE OF THE DETERMINATION OF INCOR-
 RECT  PAYMENT  TO  BE RECOVERED OR ADJUSTED. THE NOTICE OF DETERMINATION
 SHALL IDENTIFY THE EVIDENCE RELIED UPON, SET FORTH THE  FACTUAL  CONCLU-
 SIONS OF THE INVESTIGATION, AND EXPLAIN THE RECIPIENT'S RIGHT TO REQUEST
 A FAIR HEARING IN ORDER TO CONTEST THE OUTCOME OF THE INVESTIGATION. THE
 EXPLANATION OF THE RIGHT TO A FAIR HEARING SHALL CONFORM TO THE REQUIRE-
 MENTS OF SUBDIVISION TWELVE OF SECTION TWENTY-TWO OF THE SOCIAL SERVICES
 LAW AND REGULATIONS THEREUNDER.
   4.  A FAIR HEARING UNDER SECTION TWENTY-TWO OF THE SOCIAL SERVICES LAW
 SHALL BE AVAILABLE TO ANY RECIPIENT WHO RECEIVES A  NOTICE  OF  DETERMI-
 NATION  UNDER  SUBDIVISION  THREE OF THIS SECTION, REGARDLESS OF WHETHER
 THE RECIPIENT IS STILL ENROLLED IN THE MEDICAL ASSISTANCE PROGRAM.
   § 4. Paragraph (c) of subdivision 3 of section  363-d  of  the  social
 services  law,  as  amended  by section 4 of part V of chapter 57 of the
 laws of 2019, is amended and a new subdivision 8 is  added  to  read  as
 follows:
   (c)  In  the  event  that  the  commissioner of health or the Medicaid
 inspector general finds that the provider does not have  a  satisfactory
 program  [within ninety days after the effective date of the regulations
 issued pursuant to subdivision four of this section],  THE  COMMISSIONER
 OR  MEDICAID  INSPECTOR  GENERAL SHALL SO NOTIFY THE PROVIDER, INCLUDING
 SPECIFICATION OF THE BASIS OF  THE  FINDING  SUFFICIENT  TO  ENABLE  THE
 PROVIDER  TO ADOPT A SATISFACTORY COMPLIANCE PROGRAM. THE PROVIDER SHALL
 SUBMIT TO THE COMMISSIONER OR  MEDICAID  INSPECTOR  GENERAL  A  PROPOSED
 SATISFACTORY  COMPLIANCE  PROGRAM  WITHIN  SIXTY  DAYS OF THE NOTICE AND
 SHALL ADOPT THE PROGRAM AS EXPEDITIOUSLY AS POSSIBLE.  IF  THE  PROVIDER
 DOES  NOT  PROPOSE AND ADOPT A SATISFACTORY PROGRAM IN SUCH TIME PERIOD,
 the provider may be subject to any sanctions or penalties  permitted  by
 federal  or  state  laws  and  regulations,  including revocation of the
 provider's agreement to participate in the medical assistance program.
   8. ANY REGULATION, DETERMINATION OR FINDING OF THE COMMISSIONER OR THE
 MEDICAID INSPECTOR GENERAL RELATING TO A COMPLIANCE PROGRAM  UNDER  THIS
 SECTION  SHALL  BE  SUBJECT  TO AND CONSISTENT WITH SUBDIVISION THREE OF
 THIS SECTION.
 S. 4955                             5

   § 5. Section 32 of the public health law is amended by  adding  a  new
 subdivision 6-b to read as follows:
   6-B.  TO CONSULT WITH THE COMMISSIONER ON THE PREPARATION OF AN ANNUAL
 REPORT, TO BE MADE AND FILED BY THE COMMISSIONER ON OR BEFORE THE  FIRST
 DAY  OF JULY TO THE GOVERNOR, THE TEMPORARY PRESIDENT OF THE SENATE, THE
 SPEAKER OF THE ASSEMBLY, THE MINORITY LEADER OF THE SENATE, THE MINORITY
 LEADER OF THE ASSEMBLY, THE COMMISSIONER, THE COMMISSIONER OF THE OFFICE
 OF ADDICTION SERVICES AND SUPPORTS, AND THE COMMISSIONER OF  THE  OFFICE
 OF  MENTAL  HEALTH  ON  THE  IMPACTS  THAT  ALL CIVIL AND ADMINISTRATIVE
 ENFORCEMENT ACTIONS TAKEN UNDER SUBDIVISION SIX OF THIS SECTION  IN  THE
 PREVIOUS  CALENDAR YEAR WILL HAVE AND HAVE HAD ON THE QUALITY AND AVAIL-
 ABILITY OF MEDICAL CARE AND SERVICES, THE BEST  INTERESTS  OF  BOTH  THE
 MEDICAL  ASSISTANCE  PROGRAM  AND ITS RECIPIENTS, AND FISCAL SOLVENCY OF
 THE PROVIDERS WHO WERE SUBJECT TO THE CIVIL OR  ADMINISTRATIVE  ENFORCE-
 MENT ACTION;
   § 6. This act shall take effect January 1, 2028.

co-Sponsors

View additional co-sponsors

2025-S4955A (ACTIVE) - Details

See Assembly Version of this Bill:: A1069
Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §§30-a & 35, add §37, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2021-2022: S4486
2023-2024: S5329, A6813

2025-S4955A (ACTIVE) - Summary

Requires the Medicaid inspector general to comply with standards relating to the audit and review of medical assistance program funds.

2025-S4955A (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S4955A

SPONSOR: HARCKHAM
 
TITLE OF BILL:

An act to amend the public health law, in relation to the functions of
the Medicaid inspector general with respect to audit and review of
medical assistance program funds

 
PURPOSE OR GENERAL IDEA OF BILL:

To provide due process protections to health care providers in the
medical assistance program when under audit by the Office of the Medi-
caid Inspector General (OMIG).

 
SUMMARY OF PROVISIONS:

Section 1 amends Public Health Law § 30-a by adding new subdivisions,
which defines various terms including "overpayment", "applicable stand-
ards" and "clerical or minor error or omission" consistent with exiting
NYS regulations and federal Medicare standards.

§ 2 adds a new section to the Public Health Law, § 37 to include trans-
parency and due process protections for providers related to OMIG audits
and recoveries in the medical assistance program. This includes consid-
eration of the potential impacts of an audit on the provider's financial
solvency and any negative impact such repayment could have on access to
services when determining the amount of recoupment for an overpayment.
This section also prohibits any collection of repayments until 60 days
after the final audit findings or final hearing determination.

§ 3 and § 4, amends subdivision 1 of section 35 of public health law,
requiring OMIG to consult with the Commissioners of the Department of
Health and Offices of Mental Health, Addiction Services and Supports and
Developmental Disabilities on preparing and filing an annual report on
the impacts that all civil and administrative enforcement actions taken
in the previous year have had and will have on the quality and avail-
ability of medical care and services, the best interests of the medical
assistance program and its recipients, and how many audits used extrapo-
lation.

§ 5 Effective date of April 1, 2026.

 
JUSTIFICATION:

When the OMIG was created in 2007, the emphasis of the legislature and
the concern of the public was fraud and waste in the Medicaid system.
Experience with the law has made it clear that the current statute is
missing key provisions necessary to assure fairness and procedural clar-
ity for all the parties involved, including the personnel of the OMIG.

OMIG audits that punish providers for technical errors- not fraud or
abuse- do not help anyone in the Medicaid system, especially when those
errors are the result of unclear guidance or a lack of transparency.
This over-reaching approach will ultimately lead to less accessible care
and higher Medicaid costs, as people are forced to forego earlier care.

OMIG's practice of extrapolating millions of dollars in claims from a
small sample of technical errors, to meet its inflated budget targets,
is forcing already stretched-thin health, behavioral health and human
services providers to spend excessive resources on compliance and legal
defense, instead of needed health care. Such OMIG audit practices
threaten the continued viability of safety net providers, and at least
one provider has been forced to close its doors. New York's patients
cannot afford to have resources diverted, especially over unintentional
administrative errors. This bill will reign in these excessive practices
and bring equity to the Medicaid audit process

 
PRIOR LEGISLATIVE HISTORY:

2021-2022: S4486B/A7889A - Vetoed Memo. 89

2023-2024: A6813C/S5329E, amend and recommit to ways and means, Passed
senate

 
FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS:

None.

 
EFFECTIVE DATE:
This act shall take effect April 1, 2026

2025-S4955A (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  4955--A
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 14, 2025
                                ___________
 
 Introduced  by  Sens.  HARCKHAM, ADDABBO, BORRELLO, FERNANDEZ, GALLIVAN,
   MAY, MAYER, ROLISON, SEPULVEDA, WEBB -- read twice and ordered  print-
   ed,  and  when  printed  to be committed to the Committee on Health --
   committee discharged, bill amended, ordered reprinted as  amended  and
   recommitted to said committee

 AN  ACT  to amend the public health law, in relation to the functions of
   the Medicaid inspector general with respect to  audit  and  review  of
   medical assistance program funds
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 30-a of the public health law is amended by  adding
 three new subdivisions 4, 5 and 6 to read as follows:
   4. "OVERPAYMENT" SHALL MEAN ANY AMOUNT NOT AUTHORIZED TO BE PAID UNDER
 THE MEDICAL ASSISTANCE PROGRAM, WHETHER PAID AS THE RESULT OF INACCURATE
 OR  IMPROPER  COST REPORTING, IMPROPER CLAIMING, UNACCEPTABLE PRACTICES,
 FRAUD, ABUSE OR MISTAKE.
   5. "APPLICABLE STANDARDS" SHALL MEAN THE STATE LAWS,  REGULATIONS  AND
 DULY  PROMULGATED POLICIES, GUIDELINES, PROTOCOLS AND INTERPRETATIONS OF
 STATE AGENCIES WITH JURISDICTION IN EFFECT  AT  THE  TIME  THE  PROVIDER
 ENGAGED  IN  THE  REGULATED  CONDUCT  OR  PROVISION OF SERVICES THAT THE
 INSPECTOR GENERAL IS AUDITING OR REVIEWING.
   6. "CLERICAL OR MINOR ERROR OR OMISSION" SHALL INCLUDE MATHEMATICAL OR
 COMPUTATIONAL MISTAKES; TRANSPOSED PROCEDURE OR DIAGNOSTIC CODES;  INAC-
 CURATE DATA ENTRY; COMPUTER ERRORS; DUPLICATE CLAIMS; AND INCORRECT DATA
 ITEMS, SUCH AS PROVIDER NUMBER, USE OF A MODIFIER OR DATE OF SERVICE.
   §  2.  The  public health law is amended by adding a new section 37 to
 read as follows:
   § 37. AUDIT AND RECOVERY OF MEDICAL ASSISTANCE PAYMENTS TO  PROVIDERS.
 ANY  AUDIT  OR  REVIEW  OF ANY PROVIDER CONTRACTS, COST REPORTS, CLAIMS,
 BILLS, OR MEDICAL ASSISTANCE PAYMENTS BY THE  INSPECTOR,  ANYONE  DESIG-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD02919-06-5
 S. 4955--A                          2

 
 NATED  BY  THE  INSPECTOR  TO CONDUCT SUCH AUDIT OR REVIEW, SHALL COMPLY
 WITH THE FOLLOWING STANDARDS:
   1.  ANY REVIEWS OR AUDITS OF PROVIDER CONTRACTS, COST REPORTS, CLAIMS,
 BILLS OR MEDICAL ASSISTANCE PAYMENTS SHALL APPLY THE  APPLICABLE  STAND-
 ARD. PRIOR TO COMMENCING AN AUDIT OR REVIEW, THE INSPECTOR SHALL PROVIDE
 TO  THE  PROVIDER ACCESS TO ANY APPLICABLE STANDARDS. FOR THE PURPOSE OF
 THIS SUBDIVISION, AN APPLICABLE STANDARD SHALL NOT BE DEEMED  IN  EFFECT
 IF  FEDERAL  GOVERNMENTAL APPROVAL WAS PENDING OR DENIED AT THE TIME THE
 PROVIDER ENGAGED IN THE REGULATED CONDUCT OR PROVISION OF SERVICES.
   2. THE INSPECTOR SHALL PUBLISH THE MOST CURRENT VERSION  OF  PROTOCOLS
 APPLICABLE TO AND GOVERNING ANY AUDIT OR REVIEW OF A PROVIDER OR PROVID-
 ER CONTRACTS, COST REPORTS, CLAIMS, BILLS OR MEDICAL ASSISTANCE PAYMENTS
 ON  THE  OFFICE  OF THE MEDICAID INSPECTOR GENERAL WEBSITE IN ADVANCE OF
 COMMENCING SUCH AUDIT OR REVIEW, WHICH PROTOCOLS SHALL INCLUDE  ANY  AND
 ALL APPLICABLE STANDARDS.
   3.  IN  DETERMINING THE AMOUNT OF AN OVERPAYMENT A PROVIDER MUST REPAY
 FOLLOWING AN AUDIT OR REVIEW, CONSISTENT WITH SUBDIVISION SIX OF SECTION
 THIRTY-TWO OF THIS TITLE, THE  INSPECTOR  MUST  CONSIDER  THE  FOLLOWING
 FACTORS:
   (A)  WHETHER THE FINDINGS SUGGEST A SUSTAINED OR HIGH LEVEL OF PAYMENT
 ERROR;
   (B) WHETHER THE NATURE OF THE ERROR IS A CLERICAL OR  MINOR  ERROR  OR
 OMISSION;
   (C) IMPACTS TO THE PROVIDER'S FINANCIAL SOLVENCY; AND
   (D)  THE POTENTIAL FOR THE REPAYMENT, IF ORDERED, TO NEGATIVELY IMPACT
 ACCESS TO SERVICES.
   4. ANY  SAMPLING  AND  EXTRAPOLATION  METHODOLOGIES  UTILIZED  BY  THE
 INSPECTOR  SHALL BE CONSISTENT WITH ACCEPTED STANDARDS OF SOUND AUDITING
 PRACTICE AND STATISTICAL ANALYSIS.
   5. IF THE INSPECTOR DETERMINES THAT THE BASIS OF AN OVERPAYMENT  IS  A
 CLERICAL OR MINOR ERROR OR OMISSION, AND IF THE INSPECTOR FURTHER DETER-
 MINES SUCH CLERICAL OR MINOR ERROR OR OMISSION ARE ISOLATED OCCURRENCES,
 LIMITED  TO  THREE  OR LESS, THEN THE INSPECTOR SHALL NOT APPLY EXTRAPO-
 LATION IN THOSE CASES AND  RECOUPMENT  WILL  BE  LIMITED  TO  EACH  SUCH
 AFFECTED AUDITED CLAIM.
   6.  THE  DRAFT  AUDIT  REPORT  GIVEN TO THE PROVIDER SHALL INCLUDE THE
 INSPECTOR'S FINDINGS AND A DETAILED WRITTEN EXPLANATION OF THE  EXTRAPO-
 LATION  METHOD  IF  USED, INCLUDING THE SIZE OF THE SAMPLE, THE SAMPLING
 METHODOLOGY,  THE  DEFINED  UNIVERSE  OF  CLAIMS,  THE  SPECIFIC  CLAIMS
 INCLUDED  IN THE SAMPLE, THE RESULTS OF THE SAMPLE, THE ASSUMPTIONS MADE
 ABOUT THE ACCURACY AND RELIABILITY OF THE SAMPLE AND THE LEVEL OF CONFI-
 DENCE IN THE SAMPLE RESULTS, AND THE STEPS UNDERTAKEN TO  CALCULATE  THE
 ALLEGED  OVERPAYMENT  AND  ANY  APPLICABLE  OFFSET  BASED  ON THE SAMPLE
 RESULTS.
   7. THE INSPECTOR SHALL CONSIDER ANY SUPPORTING DOCUMENTATION THAT  THE
 PROVIDER  SUBMITS  PRIOR  TO THE ISSUANCE OF THE FINAL AUDIT REPORT THAT
 THE PROVIDER THINKS IS RELEVANT TO THE AUDIT, INCLUDING, BUT NOT LIMITED
 TO ATTESTATIONS ADDRESSING MISSING DOCUMENTATION AND/OR SIGNATURES.  THE
 INSPECTOR  SHALL  USE  THE  TOTALITY  OF  THE RECORD TO DETERMINE IF THE
 DOCUMENTATION OR SIGNATURE REQUIREMENT, AS OUTLINED IN STATUTE OR  REGU-
 LATION,  IS  MET,  AND/OR CONSIDER SUBMITTED ATTESTATIONS TO RESOLVE THE
 ISSUE. IF THE INSPECTOR REJECTS SUCH SUPPORTING DOCUMENTATION, AN EXPLA-
 NATION FOR SUCH REJECTION SHALL BE PROVIDED IN WRITING.
   8. THE INSPECTOR'S FINAL AUDIT REPORT OR FINAL NOTICE OF AGENCY ACTION
 SHALL INCLUDE A SPECIFIC EXPLANATION OF THE INSPECTOR'S CONSIDERATION OF
 S. 4955--A                          3
 
 THE FACTORS DESCRIBED IN PARAGRAPHS (A) THROUGH (D) OF SUBDIVISION THREE
 OF THIS SECTION.
   9.  THE  INSPECTOR  SHALL  NOT FORECLOSE OR PROHIBIT THE PROVIDER FROM
 SETTLING THROUGH REPAYMENT AT THE LOWER CONFIDENCE LIMIT PLUS APPLICABLE
 INTEREST, EVEN IF THE PROVIDER REQUESTS A HEARING, UP UNTIL THE  HEARING
 DETERMINATION IS ISSUED.
   10.  NEITHER RECOUPMENT BY THE INSPECTOR NOR REPAYMENT BY THE PROVIDER
 OF OVERPAYMENTS SHALL COMMENCE EARLIER THAN SIXTY DAYS FROM THE ISSUANCE
 DATE OF THE FINAL AUDIT REPORT OR, IF THE PROVIDER REQUESTS  A  HEARING,
 THEN SIXTY DAYS FROM THE ISSUANCE DATE OF THE HEARING DETERMINATION.
   11. NOTHING IN THIS SECTION SHALL PREVENT THE INSPECTOR FROM COMPLYING
 WITH  MEDICAID  AUDIT REQUIREMENTS ESTABLISHED BY FEDERAL LAW, RULES AND
 REGULATIONS, OR BINDING FEDERAL AGENCY GUIDANCE AND DIRECTIVES.
   § 3. The opening paragraph of subdivision  1  of  section  35  of  the
 public  health  law,  as  added  by  chapter 442 of the laws of 2006, is
 amended to read as follows:
   The inspector shall,  no  later  than  October  first  of  each  year,
 [submit]  CONSULT  WITH THE COMMISSIONER ON THE PREPARATION OF AN ANNUAL
 REPORT, TO BE MADE AND FILED BY  THE  INSPECTOR  AND  SUBMITTED  to  the
 governor,  the  temporary  president  of  the senate, the speaker of the
 assembly, THE MINORITY LEADER OF THE SENATE, THE MINORITY LEADER OF  THE
 ASSEMBLY, THE COMMISSIONER, THE COMMISSIONER OF THE OFFICE OF  ADDICTION
 SERVICES  AND  SUPPORTS,  AND  THE  COMMISSIONER OF THE OFFICE OF MENTAL
 HEALTH, THE COMMISSIONER OF THE OFFICE  OF  PERSONS  WITH  DEVELOPMENTAL
 DISABILITIES,  the state comptroller and the attorney general[, a report
 summarizing the activities of the office during the  preceding  calendar
 year]. Such report shall include:
   § 4. Paragraphs (b), (f) and (g) of subdivision 1 of section 35 of the
 public  health law, paragraph (b) as added by chapter 442 of the laws of
 2006, paragraph (f) as amended and paragraph (g) as added by section 111
 of part E of chapter 56 of the laws of 2013, are amended and a new para-
 graph (h) is added to read as follows:
   (b) the number, subject and other relevant characteristics  of  audits
 initiated,  and  those  completed, including but not limited to outcome,
 region, reason for audit and  the  total  dollar  value  identified  for
 recovery [and], the actual recovery from such audits AND HOW MANY AUDITS
 WHERE OVERPAYMENTS WERE RECOVERED USED EXTRAPOLATION;
   (f) a narrative that evaluates the office's performance, describes any
 specific  problems  and  connection  with  the procedures and agreements
 required under this section, discusses any other matters that  may  have
 impaired  its  effectiveness  and  summarizes  the  total savings to the
 state's medical assistance program; [and]
   (g) a narrative, provided by  the  department  in  its  annual  report
 pursuant  to paragraph (t) of subdivision one of section two hundred six
 of this chapter that summarizes the department's activities to  mitigate
 fraud, waste and abuse during the preceding calendar year[.]; AND
   (H)  A  NARRATIVE  THAT DESCRIBES THE STEPS TAKEN BY THE OFFICE IN THE
 PAST YEAR TO COMPLY WITH SUBDIVISION SIX OF SECTION THIRTY-TWO  OF  THIS
 TITLE,  WHICH  REQUIRES  CONSIDERATION  OF  QUALITY  AND AVAILABILITY OF
 MEDICAL AND LONG TERM CARE AND SERVICES AND THE BEST  INTEREST  OF  BOTH
 THE  MEDICAL  ASSISTANCE PROGRAM AND RECIPIENTS, IN THE PURSUIT OF CIVIL
 AND ADMINISTRATIVE ENFORCEMENT ACTIONS.
   § 5. This act shall take effect April 1, 2026.

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Senate Bill S4955A

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Sponsored By

Current Bill Status - In Senate Committee Health Committee

Bill Amendments

co-Sponsors

2025-S4955 - Details

2025-S4955 - Summary

2025-S4955 - Sponsor Memo

2025-S4955 - Bill Text download pdf

co-Sponsors

2025-S4955A (ACTIVE) - Details

2025-S4955A (ACTIVE) - Summary

2025-S4955A (ACTIVE) - Sponsor Memo

2025-S4955A (ACTIVE) - Bill Text download pdf

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