Rule 5160-1-17.3 | Provider disclosure requirements.
(A) For the purposes of this rule, the following definitions apply:
(1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(4) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (department) in accordance with 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(5) "Indirect ownership interest" means an ownership interest in an entity that has direct or indirect ownership in the disclosing provider.
(6) "Managing employee" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(7) "Person with an ownership or control interest" means a person or corporation that meets any of the following:
(a) Has an ownership interest totaling five per cent or more in the disclosing provider;
(b) Has an indirect ownership interest equal to five per cent or more in the disclosing provider;
(c) Has a combination of direct and indirect ownership interest equal to five per cent or more in the disclosing provider;
(d) Owns an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five per cent of the value of the property or assets of the disclosing provider;
(e) Is an officer or director of the disclosing provider that is organized as a corporation or non-profit; or
(f) Is a partner in the disclosing provider that is organized as a partnership or limited liability company.
(8) "Significant business transaction" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).
(B) Disclosing providers will disclose the following information to the department in accordance with 42 C.F.R. 455.104 to 42 C.F.R 455.106 (as in effect on October 1, 2023):
(1) The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing provider.
(a) In the case of an individual, date of birth and social security number.
(b) In the case of a corporation, other tax identification number with an ownership or control interest in the disclosing provider or in any subcontractor in which the disclosing provider has a five per cent or more interest.
(2) Whether the person (individual or corporation) with an ownership or control interest in the disclosing provider is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.
(3) Whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing provider has a five per cent or more interest is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.
(4) The name of any disclosing provider in which an owner of the disclosing provider has an ownership or control interest.
(5) The name, address, date of birth, and social security number of any managing employee of the disclosing provider.
(6) The identity of any person who has ownership or control interest in the disclosing provider or is an agent or managing employee of the disclosing provider, and 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.
(7) The ownership of any subcontractor with whom the disclosing provider has had business transactions totaling more than twenty-five thousand dollars during the preceding twelve-month period ending on the date the disclosure is due.
(8) Any significant business transaction between the disclosing provider and any wholly owned supplier, or between the disclosing provider and any subcontractor, during the preceding five-year period ending on the date the disclosure is due.
(C) Disclosing providers, prior to initial enrollment or revalidation with the Ohio department of medicaid (department), who are not enrolled in medicare, will at the request of the department disclose when a managing employee, within the past five years, has an affiliation with a currently or formerly enrolled medicare, medicaid, or child health insurance program (CHIP) provider or supplier that has had a disclosable event in accordance with 42 C.F.R. 455.107 (as in effect on October 1, 2023).
(1) Applicable disclosing providers will disclose the following information about each affiliation:
(a) General identifying information including:
(i) Legal name of the provider as reported to either the internal revenue service (IRS) or social security administration (SSA);
(ii) Legal name of any managing employees as reported to either the IRS or SSA;
(iii) Tax identification number (TIN); and
(iv) National provider identifier (NPI);
(b) Length of the relationship;
(c) Type of affiliation;
(d) Degree or extent of affiliation; and
(e) If the affiliation has ended, the reason for the termination.
(2) The department, in consultation with the center for medicare and medicaid services (CMS), will decide, utilizing the factors found in 42 C.F.R 455.107 (as in effect on October 1, 2023), whether the affiliation poses an undue risk of fraud, waste, and abuse.
(a) If the department determines the provider's affiliation poses an undue risk, the provider's application will be denied or if enrolled, will result in the termination of the provider agreement.
(b) If enrollment is denied or the provider agreement terminated as a result of the department determining the provider's affiliation poses an undue risk of fraud, waste, and abuse, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.
(D) Disclosures will be due at any of the following times in accordance with 42 C.F.R. 455.104 (as in effect on October 1, 2023):
(1) Prior to entering into a medicaid provider agreement or contract, during a procurement process or as part of a request for proposal.
(2) Prior to revalidating a medicaid provider agreement, or the renewal or extension of the contract.
(3) Within thirty-five days of any change in ownership.
(4) At any time within thirty-five days upon written request from the department.
(E) Failure by the disclosing provider to disclose information in accordance with this rule may result in the denial, suspension, or termination of the medicaid provider agreement or contract.
Last updated July 15, 2024 at 9:28 AM
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