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Skilled Nursing Facilities (SNFs): Provider enrollment guidelines
Last Modified: 12/12/2024
Location: FL, PR, USVI
Business: Part A, Part B
The CY 2024 Final Rule established a new rule that requires SNFs to release detailed information regarding their ownership and management as well as:
• Other parties associated with the SNF
• Ownership structures of these other parties
SNFs are now required to disclose:
• Direct ownership interest
• A direct owner has an actual ownership interest in the provider itself (e.g., owns stock in the business)
• Indirect ownership interest
• An indirect owner has an ownership interest in an organization that owns the provider or in another indirect owner. Many organizations that directly own a provider are themselves wholly or partly owned by other organizations or individuals. This is often the result of the use of holding companies and parent/subsidiary relationships. Such organizations and individuals are considered to be “indirect” owners of the provider
• General and limited partnership interests
• Report all general and limited partnership interests—regardless of the percentage. This includes all partnership interests in a non-limited partnership, and all general and limited partnership interests in a limited partnership
• Mortgage or security interest
• Report all entities with at least a five percent mortgage, deed of trust, or other security interest in the SNF. To calculate whether this interest meets the five percent threshold, use the following formula:
• Dollar amount of the mortgage, deed of trust, or other obligation secured by the SNF or any of the property or assets of the SNF divided by dollar amount of the total property and assets of the SNF
• Corporate Officers and Directors
• When the entity is organized as a corporation
• Operational or managing control or managing employees:
• Any organization that exercises operational, managerial control over the provider, or directly or indirectly conducts the day-to-day operations of the provider. The organization need not have an ownership interest in the provider to qualify as a managing organization. For instance, it could be a management services organization under contract with the provider to furnish management services for the business
• Any organization that has direct responsibility for the performance of your organization or can change the leadership, allocation of resources, or other processes of your organization to improve performance
• Any managing relationship with a management services organization under contract with the provider to furnish management services for the business. Faculty practice plans, university-based health systems, hospital outpatient departments, medical foundations, and groups that primarily treat enrollees of group model HMOs should review this definition of managing control (organizations) carefully to determine if it applies
• An individual, (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the facility. Report all managing employees of the SNF in this section. For purposes of this definition, this includes, but is not limited to, a hospice or skilled nursing facility administrator and a hospice or skilled nursing facility medical director
• All governing body members:
• SNFs must now report all members of their governing body irrespective of their business type
• For example: Partnerships or LLCs must report their governing body members. This applies for profit and non-profit entities regardless of the body's specific title
• All owners of an LLC:
• All individual and organizational owners of the LLC must be reported regardless of their percentage of ownership
• All trustees of the SNF if the SNF is established as a trust:
• Trustee can be a person or entity
• Trustees’ beneficiaries need not be reported unless they qualify for disclosure under another category (e.g., managing employee)
• All additional disclosable parties (ADPs)
• Includes all parties described in the ADP definition below, such as a person or entity that:
• Provides policies or procedures for any of the SNF's operations
• Exercises financial control over the SNF or any part thereof
• Provides financial or cash management services to the SNF
• Leases or subleases real property to the SNF
• Owns a five percent or greater interest in the total value of the SNF's real property
• Provides management or administrative services, management or clinical consulting services, or accounting or financial services to the SNF
• Persons or entities within the ADP
• For each ADP, the SNF must also report the following:
• If the ADP is a corporation:
• Officers and directors of the ADP or
• Any person or entity with a five percent or greater direct or indirect ownership interest in the ADP
• If the ADP Is an LLC:
• Any person or entity that manages the LLC or
• Any person or entity that has a direct or indirect ownership interest in the LLC, regardless of percentage
• If the ADP is a general partnership, all persons and entities with a partnership or ownership interest in the ADP, regardless of percentage
• If the ADP is a limited partnership:
• All persons and entities with a general partnership or ownership interest in the ADP, regardless of percentage
• All persons and entities with a limited partnership interest in the ADP of at least 10 percent
• If the ADP is a trust, the trustees of the trust
NOTE: Neither CMS nor MACs can instruct individual SNFs on a case-by-case basis as to which specific persons or entities within or related to their organization must be disclosed. It is ultimately the SNF’s responsibility to ascertain which such persons or entities fall within the reportable categories of parties based on the November 17, 2023, final rule (88 FR 80142) and other CMS guidance
Beginning October 1, 2024, SNFs must submit the 09/24 version of the Form CMS-855A with the SNF attachment completed. If the contractor receives the 09/23 version on or after October 1, the contractor shall follow the return process.
For 09/23 initial, reactivation, and Change of Ownership (CHOW) applications that are pending (including recommendations of approval to the state agency or PEOG) as of October 1, 2024, the contractor will develop that the SNF complete and submit the SNF attachment. The SNF has until May 1, 2025, to submit the attachment.
• If the SNF submits the attachment but it is incomplete or otherwise deficient, the contractor shall send another development letter to the SNF. The SNF has 15 calendar days from the date of the letter to furnish the correct or complete data
• If the SNF does not submit the attachment or respond to development on the attachment, the contractor shall contact its PEOG BFL for guidance
All SNFs must complete Attachment 1 with their application during:
• Initial enrollment
• Revalidation
• Reactivation
• Change of information (only required if changes are needed on Attachment 1)
• Change of Ownership
NOTE: CMS will conduct an off-cycle revalidation of all SNFs. The revalidations will occur in three evenly distributed stages commencing on October 1, November 1, and December 1 of 2024. The SNF will have until May 1, 2025, to submit the 09/24 version of the Form CMS-855A.
If multiple organizations have ownership or managing control, complete sections A-E for each organization
Section A, Organization Identification Information:
• Report all required information
• Note: The legal business name must be what is reported to the IRS
Section B, Type of Organization:
• For the organization listed in section A, identify:
• How the business is registered with the IRS
• Type of business structure
• Type of organization:
• For organization definitions, reference the definition section below
• Provide answers to additional questions regarding the organization
Section C, Chain Home Offices Only:
• This section is only required if the SNF itself is part of a chain. It does not apply to entities listed in section A of the attachment.
Section D, Relationship to SNF or to Additional Disclosable Party of SNF:
• Questions 1-5 should only be completed as it applies to your business structure
• Example: If the SNF reported in section 2 of the CMS-855A is a corporation, section D1 must be completed
• Question 5 would include SNFs that are government agencies and sole proprietorships
• If yes is selected, complete all fields for the entity
• Questions 6-7 should only be completed as it applies to your business structure
• Example: If the SNF reported in section 2 of the CMS-855A is a corporation, section D6 must be completed
• If yes is selected, complete all fields for the entity
• Questions 8-13 are required for every organization listed in section A
• Question 10: If answered "Yes", complete the operational, managerial, and financial fields
• If an entity exercises multiple types of control or different parts of the SNF are involved, the SNF must differentiate between them when responding to (i), (ii), and (iii). For instance, if operational and financial control are involved, the SNF must identify and clearly distinguish the types and parts in the same box (i.e., describe the forms of financial control, which parts they pertain to, the types of managerial control, etc.)
• Question 11: If answered "Yes", complete all remaining questions
• If an entity provides multiple types of service, the SNF must differentiate between them when furnishing the required description in Question 11
• If yes is selected, complete all additional fields for the entity
• Questions 14-18 are required for every organization listed in section A
• Additional disclosable party: Reference the Definition section below
• The SNF must disclose whether the reported entity has any ownership or trustee interests in any ADP of the SNF. An ADP will effectively be identified as such if the SNF answered “Yes” to Question 9, 10, 11, 12, or 13 for any entity reported on the attachment
• If yes is selected, complete all additional fields for the entity
• Question 19: Only required if "Yes" was answered to question 14, 15, 16, 17, or 18
Section E, Final Adverse Legal Action:
• Complete this section for each individual listed in section A
• If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable
If multiple individuals have ownership or managing control, complete sections A-C for each individual
Section A, Individual Identifying Information:
• Report all required information
• Note: The first and last name, social security number, and date of birth must match what is reported to the Social Security Administration
Section B, Relationship to SNF or Additional Disclosable Party (ADP) of SNF:
• Questions 1-5 should only be completed if it applies to your business structure:
• Example: If the SNF reported in section 2 of the CMS-855A is a corporation, section B1 must be completed
• Question 5 would include SNFs that are government agencies and sole proprietorships
• If yes is selected, complete all fields for the individual
• Questions 6-7 should only be completed if it applies to your business structure:
• Example: If the SNF reported in section 2 of the CMS-855A is a corporation, section B6 must be completed
• If yes is selected, complete all fields for the individual
• Questions 8 must be completed if the SNF is a corporation
• If yes is selected, complete all fields for the individual
• Questions 9 must be completed if the SNF is not a corporation
• The only exception to this requirement is if a governmental or tribal organization will be legally and financially responsible for Medicare payments the SNF receives (as explained in Section 6 of the Form CMS-855A). In this case, the governing body members of the governing or tribal organization (e.g., members of state health commission, city council members) need not be reported as governing body members in Section A or in Question 9. However, they may need to be disclosed as an individual in Section A in another capacity, such as a person who exercises operational control over or who is a managing employee of the SNF
• If yes is selected, complete all fields for the individual
• Questions 10-16 must be answered for each individual:
• If an entity listed in the organizations section of the attachment exercises control over or furnishes services to the SNF, persons within that organization who exercise or furnish said control or services must also be disclosed as individual in the individuals section
• Question 12: If answered "Yes", complete the operational, managerial, and financial fields
• If an individual exercises multiple types of control or different parts of the SNF are involved, the SNF must differentiate between them when responding to (i), (ii), and (iii). For instance, if operational and financial control are involved, the SNF must identify and clearly distinguish the types and parts in the same box (i.e., describe the forms of financial control, which parts they pertain to, the types of managerial control, etc.)
• Question 13: If answered "Yes", complete all remaining services
• If an individual provides multiple types of services, the SNF must differentiate between them when furnishing the required description in Question 13
• Question 16: This is required if the individual is the SNF medical director or administrator. The SNF's medical director or administrator must fall within the definition of managing employee and must be reported in section A of the attachment
• At least one reported individual must be identified as the administrator and another as the medical director
• If yes is selected, complete all additional fields for the individual
• Questions 17-22 must be answered for each individual:
• Additional disclosable party (ADP): Reference the definition section below
• The SNF must disclose whether the reported individual has any ownership or trustee interests in any ADP of the SNF. An ADP will effectively be identified as such if the SNF answered “Yes” to question 9, 10, 11, 12, or 13 for any entity reported on the attachment
• If yes is selected, complete all additional fields for the individual
• Question 23:
• Only required if "Yes" was answered to question 17, 18, 19, 20, 21, or 22
Section C, Final Adverse Legal Action:
• Complete this section for each individual listed in section A
• If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable
Supporting documentation is required for a newly enrolling SNF as well as certain change of information applications. If you are adding, changing, or deleting information in Attachment 1, please also include:
• Chart identifying all entities in Attachment 1, Section A and show their relationships with the SNF and each other
• Chart identifying organizational structures of all owners, including owners not listed in this attachment (e.g., less than five percent direct or indirect owners)
• Chart outlining the organizational structures of each ADP of the facility. This must include a written description of the relationship of each ADP to the facility and to all the SNF's other ADPs.
At least one of the charts must also identify the SNF's ultimate parent company and the entities between the SNF and the parent in the organizational arrangement
Additional disclosable party:
• Any organization that exercises operational, financial, or managerial control over the facility, provides policies and procedures for any of the operations of the facility, or provides financial or cash management services to the facility
• Any organization that leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding five percent of the total value of such real property; or
• Any organization that provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility
Direct ownership interest*:
• Direct owner has an actual ownership interest in the provider itself (e.g., owns stock in the business)
Holding company:
• Business entity, usually a corporation or limited liability company (LLC), created to hold the controlling stock or membership interests in other companies
Indirect ownership interest*:
• Indirect owner has an ownership interest in an organization that owns the provider or in another indirect owner
General and limited partnerships interests:
• Report all general and limited partnership interests, regardless of percentage. This includes all partnership interests in a non-limited partnership, and all general and limited partnership interests in a limited partnership
Managing employee:
• An individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the SNF
Mortgage or security interest*:
• Report all entities with at least a five percent mortgage, deed or trust, or other security interest in the SNF. To calculate whether this interest meets the five percent threshold, use the following formula:
• Dollar amount of the mortgage, deed or trust, or other obligation secured by the SNF or any of the property or assets of the SNF divided by dollar amount of the total property and assets of the SNF
Operational or managing control:
• Any organization that exercises operational, managerial control over the provider, or directly or indirectly conducts the day-to-day operations of the provider. The organization need not have an ownership interest in the provider to qualify as a managing organization. For instance, it could be a management services organization under contract with the provider to furnish management services for the business
• Any organization that has direct responsibility for the performance of your organization or can change the leadership, allocation of resources, or other processes of your organization to improve performance
• Any managing relationship with a management services organization under contract with the provider to furnish management services for the business. Faculty practice plans, university-based health systems, hospital outpatient departments, medical foundations, and groups that primarily treat enrollees of group model HMOs should review this definition of managing control (organizations) carefully to determine if it applies
Organization structure:
• For corporations: The corporation’s officers, directors, and five percent or greater shareholders
• For limited liability companies (LLCs): The LLC’s members and managers (including, as applicable, the percentage of ownership each member and manager has in the LLC)
• For general partnerships: The partners in the general partnership
• For limited partnerships: The general partners as well as any limited partners who own at least 10 percent of the limited partnership
• For trusts: The trustees of the trust
Private equity company (Medicare purposes):
• Publicly traded or non-publicly traded company that collects capital investments from individual or entities (like investors) and purchases a direct or indirect ownership share of a provider (like a SNF or home health agency)
Real estate investment trust (Medicare purposes):
• Real estate investment trust as defined in 26 U.S.C § 856. (Reference 42 C.F.R. § 424.502)
*Reference the paper CMS-855A for examples.
Accounting Services – Can include an accountant or accounting company the SNF hires or contracts with to perform any accounting activity for the SNF. (This can include in-house and outside auditors the SNF hires). The person need not be a Certified Public Accountant to qualify for disclosure. It is the provision of the accounting service itself, rather than the professional status or title of the party furnishing it, that is determinative
Administrative Services – Can involve services such as, but not limited to, compliance or oversight, human resources, public relations, outreach or advertising, technical assistance to the SNF’s main information system, etc. (This category does not include custodial, building security, and similar services.)
Cash Management Services – Can include parties that give guidance or advice on cash flow and other financial matters; handling the SNF’s financial transactions, such as ACH payments and mobile banking; etc. (To reiterate, this short list is not exhaustive. There are many types of services that could fall within the category of cash management.)
Clinical Consulting Services – Can involve assessing or advising how to improve or modify any aspect of the SNF’s provision of health care. (Note that the person or entity need not have a medical license or have the formal title of “clinical consultant” or “clinical consulting” firm to qualify for disclosure. It is the type of service involved (not the person’s title or medical certification) that is critical.)
Financial Control – Can include monitoring or managing the SNF’s finances; authority to approve the expenditure of SNF funds; an owning organization of the SNF that funds part of the SNF’s operations; etc.
Financial Services – Can include investment banking, investment management, asset management, financial advice, accounting, etc.
Managerial Control – Includes parties falling within the definition of “managing employee” or “managing organization” in § 424.502, such as: (1) supervisors; or (2) non-supervisors who nonetheless oversee and are responsible for any aspect of the SNF’s operations. (Number (2) does not mean every SNF employee who is responsible for any action in the SNF’s organization (e.g., nurse, administrative assistant) need be reported. There must be some degree of broader oversight and decision-making authority involved.)
Management Services – Includes parties that furnish to the SNF the services described in (vii) above under contract or other arrangement with the SNF (e.g., management company).
Operational Control – Includes persons or entities that oversee and have responsibility for any aspect of the SNF’s daily activities or transactions (e.g., person in charge of the SNF’s (1) medical records, (2) patient activities, or (3) dietary or food operations). The person need not serve in a supervisory role to have operational control.
“Part” of the Facility – Includes any physical or operational portion of the facility (e.g., a separate wing of the facility; social worker unit; nursing unit).
Policies or Procedures – Includes persons or entities responsible for developing or furnishing guidelines regarding the execution of any aspect of the SNF’s operations (e.g., consultant hired to prepare emergency or evacuation plans, patient treatment procedures, patient transfer procedures, etc.)
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
