The Wait Is Over: Revised CMS Enrollment Form Puts SNF Ownership and Management Under a Microscope

With the release of an updated CMS-855A enrollment form (855A), skilled nursing facilities (SNFs) will be required to identify substantially more detailed ownership and control information to Centers for Medicare and Medicaid Services (CMS). CMS is also initiating off-cycle revalidations for all SNFs from October to December 2024 and is requiring use of the revised 855A.

SNFs were put on notice in late 2023 that these additional Medicare disclosures of ownership and control information were forthcoming, in light of a final rule issued by CMS on 17 November 2023 (Final Rule) to implement requirements of the Affordable Care Act. The Final Rule promulgated regulations that were effective 16 January 2024. However, SNFs were granted a reprieve from having to comply with the new disclosure requirements while CMS updated the 855A to collect the required information.

The reprieve is officially over. CMS recently released an updated 855A enrollment form with accompanying sub-regulatory guidance (initially published on 24 September 2024 and revised on 8 October 2024) as contemplated by the Final Rule. Effective 1 October 2024, SNFs must use the revised 855A for initial enrollments, revalidations, reactivations, changes of ownership, and changes of information.

SNF Medicare Enrollment Requirements

Disclosures of SNF ownership and managing control information are not new. Prior to the release of the newly revised 855A, SNFs reported the same information as other institutional providers under Sections 5 and 6 of the form. Under the revised 855A, however, SNFs will check a box to skip Sections 5 and 6 and will instead complete a more comprehensive 19-page form titled “Attachment 1: Skilled Nursing Facility Disclosures” reserved just for SNFs (Attachment 1).

SNFs should be aware that Attachment 1 likely requires significant time to complete and may necessitate additional information gathering. While some of the disclosure requirements from Sections 5 and 6 carry over into the new Attachment 1, there are several new or additional disclosure requirements. For example:

1. SNFs are required to report all members of their governing body irrespective of their business type.
2. If the SNF is a limited liability company (LLC), all owners must be reported regardless of their percentage of ownership. Previously, owners with interests of less than 5% were not required to be reported.
3. If the SNF is established as a trust, the SNF must disclose all of its trustees.
4. SNFs must now also identify and report all Additional Disclosable Parties (ADPs) and information about persons and entities that have an ownership or management interest in the ADP. An ADP is a person or entity that (i) exercises operational, financial, or managerial control over all or part of the SNF, provides policies or procedures for the SNFs operations, or provides financial or cash management services to the SNF; (ii) leases or subleases real property to the SNF or owns a whole or part interest of at least 5% of the total value of the real property; or (iii) provides management or administrative services, management or clinical consulting services, or accounting or financial services to the SNF.
5. Certain additional disclosures are required where an ADP is an entity; for example, if an ADP is an LLC, the SNF must disclose any person or entity that manages the LLC as well as any person or entity that has any ownership interest in the LLC, regardless of the percentage of ownership.

Notably, the release of the revised 855A also coincides with an announcement from CMS that it will perform off-cycle revalidations for all enrolled SNFs between October and December 2024. This means that Medicare-enrolled SNFs should expect to receive a revalidation notice before the end of the 2024 calendar year and will need to complete Attachment 1 as part of the revalidation process. Additionally, SNFs that have a pending initial enrollment, revalidation, change of ownership, or reactivation application using the prior version of the 855A will be required to complete Attachment 1.

The new disclosure requirements are both extensive and complex, and so SNFs should take time now to review closely Attachment 1 and begin collecting the required information. SNFs should expect to devote a considerable amount of time preparing these materials and will need to put processes in place to collect and timely report changes in information going forward. Similarly, for SNFs contemplating mergers, joint ventures, or acquisitions, understanding these disclosure requirements will be crucial to ensure reporting in accordance with these new obligations. A failure to disclose or update the required information could lead to a denial or revocation of the SNF’s Medicare enrollment and billing privileges.

SNF Medicaid Enrollment Requirements

Medicaid-enrolled nursing facilities should anticipate forthcoming changes to the disclosure requirements applicable to Medicaid enrollments. In addition to the updated Medicare enrollment provisions, the Final Rule also included revisions to the federal Medicaid provider enrollment requirements and instructed state Medicaid agencies to: (1) establish the necessary data collection mechanisms; and (2) start requiring Medicaid nursing facilities to provide this data once these collection means are established. Although nursing facilities will not need to report the required data until the applicable state Medicaid agency has established the means to collect it, Medicaid-enrolled nursing facilities should begin monitoring Medicaid agency announcements for changes to enrollment requirements.

Key Takeaways

These updates represent a significant change in the Medicare enrollment criteria for SNFs. While CMS’s sub-regulatory guidance includes some examples, given the complexity of these new disclosure requirements, CMS expressly recommends that SNFs contact their legal counsel or other professional advisor for assistance with questions about the applicability of the new disclosure requirements to specific individuals and entities within the organization.

Our Health Care practice routinely assists health systems, hospitals, skilled nursing facilities, and other providers with legal advice on enrollment, certification, and reimbursement matters. Contact the authors of this article or another of our health care lawyers for assistance with any of these important issues.