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Notes

42 C.F.R. §§ 455.104–455.107

4 sections in range

§455.104. Disclosure by Medicaid providers and fiscal agents: Information on ownership and control.

42 C.F.R. § 455.104

(a)
Who must provide disclosures. The Medicaid agency must obtain disclosures from disclosing entities, fiscal agents, and managed care entities.
(b)
What disclosures must be provided. The Medicaid agency must require that disclosing entities, fiscal agents, and managed care entities provide the following disclosures:
(1)
(i)
The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or managed care entity. The address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.
(ii)
Date of birth and Social Security Number (in the case of an individual).
(iii)
Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) or in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest.
(2)
Whether the person (individual or corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling.
(3)
The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an ownership or control interest.
(4)
The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity).
(c)
When the disclosures must be provided—
(1)
Disclosures from providers or disclosing entities. Disclosure from any provider or disclosing entity is due at any of the following times:
(i)
Upon the provider or disclosing entity submitting the provider application.
(ii)
Upon the provider or disclosing entity executing the provider agreement.
(iii)
Upon request of the Medicaid agency during the re-validation of enrollment process under § 455.414.
(iv)
Within 35 days after any change in ownership of the disclosing entity.
(2)
Disclosures from fiscal agents. Disclosures from fiscal agents are due at any of the following times:
(i)
Upon the fiscal agent submitting the proposal in accordance with the State's procurement process.
(ii)
Upon the fiscal agent executing the contract with the State.
(iii)
Upon renewal or extension of the contract.
(iv)
Within 35 days after any change in ownership of the fiscal agent.
(3)
Disclosures from managed care entities. Disclosures from managed care entities (MCOs, PIHPs, PAHPs, and HIOs), except PCCMs are due at any of the following times:
(i)
Upon the managed care entity submitting the proposal in accordance with the State's procurement process.
(ii)
Upon the managed care entity executing the contract with the State.
(iii)
Upon renewal or extension of the contract.
(iv)
Within 35 days after any change in ownership of the managed care entity.
(4)
Disclosures from PCCMs. PCCMs will comply with disclosure requirements under paragraph (c)(1) of this section.
(d)
To whom must the disclosures be provided. All disclosures must be provided to the Medicaid agency.
(e)
Nursing facilities.
(1)
In addition to all other applicable reporting requirements in this subpart, a nursing facility (as defined in section 1919(a) of the Act) must disclose upon initial enrollment and revalidation the following information:
(i)
Each member of the governing body of the facility, including the name, title, and period of service for each such member.
(ii)
Each person or entity who is an officer, director, member, partner, trustee, or managing employee (as defined in § 455.101) of the facility, including the name, title, and period of service of each such person or entity.
(iii)
Each person or entity who is an additional disclosable party of the facility (as defined in § 455.101).
(iv)
The organizational structure (as defined in § 455.101) of each additional disclosable party of the facility and a description of the relationship of each such additional disclosable party to the facility and to one another.
(2)
The State need not require the facility to disclose the same information described in this paragraph (e) more than once on the same enrollment application submission.
(f)
Consequences for failure to provide required disclosures. Federal financial participation (FFP) is not available in payments made to a disclosing entity that fails to disclose ownership or control information as required by this section.
Notes, amendments, and revision history

Amendments

[76 FR 5967, Feb. 2, 2011, as amended at 88 FR 80169, Nov. 17, 2023]

Source

Source: 44 FR 41644, July 17, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[76 FR 5967, Feb. 2, 2011, as amended at 88 FR 80169, Nov. 17, 2023]

§455.105. Disclosure by providers: Information related to business transactions.

42 C.F.R. § 455.105

(a)
Provider agreements. A Medicaid agency must enter into an agreement with each provider under which the provider agrees to furnish to it or to the Secretary on request, information related to business transactions in accordance with paragraph (b) of this section.
(b)
Information that must be submitted. A provider must submit, within 35 days of the date on a request by the Secretary or the Medicaid agency, full and complete information about—
(1)
The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and
(2)
Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.
(c)
Denial of Federal financial participation (FFP).
(1)
FFP is not available in expenditures for services furnished by providers who fail to comply with a request made by the Secretary or the Medicaid agency under paragraph (b) of this section or under § 420.205 of this chapter (Medicare requirements for disclosure).
(2)
FFP will be denied in expenditures for services furnished during the period beginning on the day following the date the information was due to the Secretary or the Medicaid agency and ending on the day before the date on which the information was supplied.
Notes, amendments, and revision history

Source

Source: 44 FR 41644, July 17, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

§455.106. Disclosure by providers: Information on persons convicted of crimes.

42 C.F.R. § 455.106

(a)
Information that must be disclosed. Before the Medicaid agency enters into or renews a provider agreement, or at any time upon written request by the Medicaid agency, the provider must disclose to the Medicaid agency the identity of any person who:
(1)
Has ownership or control interest in the provider, or is an agent or managing employee of the provider; and
(2)
Has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or the title XX services program since the inception of those programs.
(b)
Notification to Inspector General.
(1)
The Medicaid agency must notify the Inspector General of the Department of any disclosures made under paragraph (a) of this section within 20 working days from the date it receives the information.
(2)
The agency must also promptly notify the Inspector General of the Department of any action it takes on the provider's application for participation in the program.
(c)
Denial or termination of provider participation.
(1)
The Medicaid agency may refuse to enter into or renew an agreement with a provider if any person who has an ownership or control interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person's involvement in any program established under Medicare, Medicaid or the title XX Services Program.
(2)
The Medicaid agency may refuse to enter into or may terminate a provider agreement if it determines that the provider did not fully and accurately make any disclosure required under paragraph (a) of this section.
Notes, amendments, and revision history

Source

Source: 44 FR 41644, July 17, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

§455.107. Disclosure of affiliations.

42 C.F.R. § 455.107

(a)
Definitions. For purposes of this section only, the following terms apply to the definition of disclosable event in § 455.101:
(1)
“Uncollected debt” only applies to the following:
(i)
Medicare, Medicaid, or CHIP overpayments for which CMS or the State has sent notice of the debt to the affiliated provider or supplier.
(ii)
Civil money penalties imposed under this title.
(iii)
Assessments imposed under this title.
(2)
“Revoked,” “Revocation,” “Terminated,” and “Termination” include situations where the affiliated provider or supplier voluntarily terminated its Medicare, Medicaid, or CHIP enrollment to avoid a potential revocation or termination.
(b)
General.
(1)
(i)
Selection of option. A State, in consultation with CMS, must select one of the two options identified in paragraph (b)(2) of this section for requiring the disclosure of affiliation information.
(ii)
Change of selection. A State may, in consultation with CMS, change its selection after it has been made from the option in paragraph (b)(2)(ii) of this section to that in paragraph (b)(2)(i) of this section.
(2)
(i)
First option. In a State that has selected the option in this paragraph (b)(2)(i), a provider that is not enrolled in Medicare but is initially enrolling in Medicaid or CHIP (or is revalidating its Medicaid or CHIP enrollment information) must disclose any and all affiliations that it or any of its owning or managing employees or organizations (consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101) has or, within the previous 5 years, had with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event (as defined in § 455.101).
(ii)
Second option. In a State that has selected the option in this paragraph (b)(2)(ii), and upon request by the State, a provider that is not enrolled in Medicare but is initially enrolling in Medicaid or CHIP (or is revalidating its Medicaid or CHIP enrollment information) must disclose any and all affiliations that it or any of its owning or managing employees or organizations (consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101) has or, within the previous 5 years, had with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event (as defined in § 455.101). The State will request such disclosures when it, in consultation with CMS, has determined that the initially enrolling or revalidating provider may have at least one such affiliation.
(c)
Information. The initially enrolling or revalidating provider must disclose the following information about each affiliation:
(1)
General identifying information about the affiliated provider or supplier, which includes the following:
(i)
Legal name as reported to the Internal Revenue Service or the Social Security Administration (if the affiliated provider or supplier is an individual).
(ii)
“Doing business as” name (if applicable).
(iii)
Tax identification number.
(iv)
National Provider Identifier (NPI).
(2)
Reason for disclosing the affiliated provider or supplier.
(3)
Specific data regarding the affiliation relationship, including the following—
(i)
Length of the relationship.
(ii)
Type of relationship.
(iii)
Degree of affiliation.
(4)
If the affiliation has ended, the reason for the termination.
(d)
Mechanism. The information described in paragraphs (b) and (c) of this section must be furnished to the State in a manner prescribed by the State in consultation with the Secretary.
(e)
Denial or termination. The failure of the provider to fully and completely report the information required in this section when the provider knew or should reasonably have known of this information may result in, as applicable, the denial of the provider's initial enrollment application or the termination of the provider's enrollment in Medicaid or CHIP.
(f)
Undue risk. Upon receipt of the information described in paragraphs (b) and (c) of this section, the State, in consultation with CMS, determines whether any of the disclosed affiliations poses an undue risk of fraud, waste, or abuse by considering the following factors:
(1)
The duration of the affiliation.
(2)
Whether the affiliation still exists and, if not, how long ago the affiliation ended.
(3)
The degree and extent of the affiliation.
(4)
If applicable, the reason for the termination of the affiliation.
(5)
Regarding the affiliated provider's or supplier's disclosable event under paragraph (b) of this section, all of the following:
(i)
The type of disclosable event.
(ii)
When the disclosable event occurred or was imposed.
(iii)
Whether the affiliation existed when the disclosable event occurred or was imposed.
(iv)
If the disclosable event is an uncollected debt—
(A)
The amount of the debt;
(B)
Whether the affiliated provider or supplier is repaying the debt; and
(C)
To whom the debt is owed.
(v)
If a denial, revocation, termination, exclusion, or payment suspension is involved, the reason for the disclosable event.
(6)
Any other evidence that the State, in consultation with CMS, deems relevant to its determination.
(g)
Determination of undue risk. A determination by the State, in consultation with CMS, that a particular affiliation poses an undue risk of fraud, waste, or abuse will result in, as applicable, the denial of the provider's initial enrollment in Medicaid or CHIP or the termination of the provider's enrollment in Medicaid or CHIP.
(h)
Undisclosed affiliations. The State, in consultation with CMS, may apply paragraph (g) of this section to situations where a reportable affiliation (as described in paragraphs (b) and (c) of this section) poses an undue risk of fraud, waste, or abuse, but the provider has not yet disclosed or is not required at that time to disclose the affiliation to the State.
Notes, amendments, and revision history

Amendments

[84 FR 47856, Sept. 10, 2019, as amended at 87 FR 70249, Nov. 18, 2022]

Source

Source: 44 FR 41644, July 17, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[84 FR 47856, Sept. 10, 2019, as amended at 87 FR 70249, Nov. 18, 2022]