CMS Releases Update to CMS-855A Enrollment Form With Significant Increase in Disclosure Requirements for SNFs

The Centers for Medicare & Medicaid Services (“CMS”) has issued an updated version of the Form CMS-855A that requires additional disclosures for skilled nursing facilities (“SNFs”). Effective October 1, 2024, the revised Form CMS-855A must be used for all filings associated with initial enrollment, revalidation, reactivation, and change of ownership. The new SNF-specific disclosures are included in a new Attachment 1 of the Form CMS-855A. Attachment 1 replaces Sections 5 and 6 of the previous version of the Form CMS-855A, but only with respect to SNFs. The following information is captured in Attachment 1:

• All SNF data previously disclosed in Sections 5 and 6 of the Form CMS-855A;
• Other parties associated with the SNF;
• The ownership structures of such associated parties; and
• Organizational structure diagrams of all entities/individuals identified in SNF Attachment 1, including relationships with the providers and owners with less than 5% direct/indirect ownership (even if a SNF Attachment 1 for this owner is not provided).

These most recent updates come after CMS’ recent focus on 855A disclosures in the past few years, discussed in previous AGG articles.

What Entities and Individuals Must Be Disclosed in SNF Attachment 1?

The SNF Attachment 1 requires reporting of following information:

1. Each member of the SNF governing body.
   • Each person or entity who is an officer, director, member, partner, trustee, or managing employee (as defined in § 424.502) of the SNF.
   • Each person or entity who is an additional disclosable party (“ADP”) of the SNF.
   • The organizational structure of each ADP of the SNF and a description of the relationship of each ADP to the facility and to one another.
2. If the SNF is an LLC, all individual and organizational owners of the LLC must be reported regardless of their percentage of ownership. There is no longer a 5% threshold for this disclosure. The 5% threshold remains if the SNF is a corporation for purposes of filling out Attachment 1, though owners with less than 5% must be disclosed in an organizational chart.
3. Additional Disclosable Parties: Any person or entity who falls into the following three categories:
   • Control
     • Exercises operational, financial, or managerial control over the SNF or a part thereof, or provides policies or procedures for any of the SNF operations, or provides financial or cash management services to the SNF;
   • Real Estate
     • Leases or subleases real property to the SNF, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property; or
   • Management
     • Provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility.

CMS has issued guidance regarding specific examples of potential ADPs that should be disclosed, including:

• Accounting Services: Can include an accountant or accounting company the SNF hires or contracts with to perform any accounting activity (e.g., preparation of cost reports) for the SNF. (This can include in-house and outside auditors the SNF hires).
• Administrative Services: Can involve services such as, but not limited to, compliance/oversight, human resources, public relations/outreach/advertising, technical assistance to the SNF main information system, etc. (This category does not include custodial, building security, and similar services.)
• Cash Management Services: Can include parties that give guidance/advice on cash flow and other financial matters; handling the SNF’s financial transactions, such as ACH payments and mobile banking; etc.
• Clinical Consulting Services: Can involve assessing or advising how to improve or modify any aspect of the SNF’s provision of healthcare.
• 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; banks that have given the SNF a line of credit; 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, including management/oversight of matters such as maintenance. (Number (2), however, 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 above under contract or other arrangement with the SNF (e.g., a management company).
• Operational Control: Includes persons/entities that oversee and have responsibility for any aspect of the SNF daily activities or transactions (e.g., person in charge of the SNF (1) medical records; (2) patient activities; or (3) dietary/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/entities responsible for developing or furnishing guidelines regarding the execution of any aspect of the SNF operations (e.g., consultant hired to prepare emergency/evacuation plans, patient treatment procedures, patient transfer procedures, etc.)

ADP Entity Disclosures – SNF Attachment 1

Below is a high-level summary of key information that is required in the SNF Attachment 1 if an entity is identified as an ADP of the provider. However, all requests in the SNF Attachment 1 should be reviewed carefully for potential disclosure for each ADP. All entities identified in SNF Attachment 1 must comply with requirements to disclose any adverse actions.

For each ADP, the SNF must also report the following persons/entities associated with the ADP (please also see helpful sections of the 855A application form below):

• Officers/directors/managers of the ADP.
• For corporations only, any person/entity with 5% or greater direct/indirect ownership of the ADP.
• For LLCs, any person or entity with direct/indirect ownership of the ADP (regardless of the percentage).
• For general partnerships, any person or entity with partnership/ownership of the ADP (regardless of the percentage).
• For limited partnerships, any person or entity with general partnership/ownership of the ADP (regardless of the percentage) and any person or entity with limited partnership/ownership of the ADP.
• For trusts, trustees of the trust.

Pg. 56 of CMS 855A – Classification Types

Pg. 58 of CMS 855A

Pg. 59 of CMS 855A

Pg. 60 of CMS 855A

Pg. 61 of CMS 855A

ADP Individual Disclosures – SNF Attachment 1

Below is a high-level summary of key information that is required in the SNF Attachment 1 if an individual is identified as an ADP of the provider (see 855A application sections below). However, all requests in the SNF Attachment 1 should be reviewed carefully for potential disclosure for each ADP. All individuals identified in SNF Attachment 1 must comply with requirements to disclose any adverse actions.

Pg. 67 of CMS 855A

When Must a SNF Submit a New or Updated SNF Attachment 1

• Any changes to information disclosed in the SNF Attachment 1 must be submitted within 30 days of the change, including:
  • 5% or greater direct or indirect owners of the SNF.
  • General or limited partners of the SNF (regardless of the percentage).
  • Managing organizations or employees of the SNF (as the term “managing employee” is defined in 42 CFR § 424.502). This includes question 16 of the Individuals section regarding medical directors and administrators.
  • Corporate officers of the SNF.
  • Corporate directors of the SNF.
  • Persons with a 5% or greater mortgage or security interest in the SNF.
  • Trustee interests in the SNF.
  • Any types of control or services as described in questions 10 and 11 of the Organizations section and questions 12 and 13 of the Individuals section.
  • Information on organizations and individuals that lease or sublease real property to the SNF (i.e., question 12 of the Organizations section and question 14 of the Individuals section).
  • Ownership of total value of SNF’s real property or the property on/in which the SNF operates (i.e., question 13 of the Organizations section and question 15 of the Individuals section).
• All other changes to data on the SNF Attachment 1 must be reported within 90 days of the change.

Upcoming Off-Cycle Revalidations

CMS has announced that SNFs will soon begin receiving off-cycle Medicare revalidation notices from their Medicaid Administrative Contractor (“MAC”). The planned revalidations are scheduled to take place between October and December 2024. SNFs should begin reviewing the new requirements now in order to ensure accurate reporting in the coming months.

For more information, please contact AGG Healthcare partners Hedy Rubinger or Alexander Foster.

 

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