Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-1 - General Provisions
Section 5160-1-17.3 - Provider disclosure requirements
Universal Citation: OH Admin Code 5160-1-17.3
Current through all regulations passed and filed through September 16, 2024
(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.
Replaces: 5160-1-17.3
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